
Glass. 
Book 



COPYRIGHT DEPOSIT 



DISEASES 

OF THE 

NOSE, THROAT, AND EAR 

BISHOP 



DISEASES 



OF THE 



NOSE, THROAT, AND EAR 



AND 



THEIR ACCESSORY CAVITIES 



BY 

SETH SCOTT BISHOP, M.D., D.C.L., LL.D. 

Author of "The Ear and its Diseases." 

Honorary President of the Faculty and Professor of Diseases of the Nose, Throat, and Ear in the 
Illinois Medical College ; Professor in the Chicago Post-graduate Medical School and Hospital ; 
Surgeon to the Post-graduate Hospital and to the Illinois Hospital ; Consulting Surgeon to 
the Mary Thompson Hospital, to the Illinois Masonic Orphans' Home, and to the 
Silver Cross Hospital of Joliet ; Formerly Surgeon to the Illinois Chari- 
table Eye and Ear Infirmary, to the South-side Free Dispensary, 
and to the West-side Free Dispensary ; Editor of the 
Illinois Medical Bulletin ; One of the Editors 
of the Laryngoscope, etc. 



Third Edition. Tliorouglily Revised and Enlarged 



Illustrated with Ninety-four Colored Lithographs and Two 
Hundred and Thirty Additional Illustrations 




PHILADELPHIA 

F. A. DAVIS COMPANY, PUBLISHERS 

1904 






S0W6RPSS 
f«vr> Annies Revived 

OCT 22 1904 

GLASS ^ XXo: Nd 



^ ■-" ^1 ! . .. , 



COPYRIGHT, 1904, 

BY 

F. A. DAVIS COMPANY. 



[Registered at Stationers' Hall. London, Eng.] 



Philadelphia, Pa., U. S. A. 

The Medical Bulletin Printing-house, 

1914-16 Cheny Street. 



TO 



Prof. Nicholas Senn, M.D., Ph.D., LLD., 

IN RECOGNITION OF HIS DISTINGUISHED 
SERVICES 

IN THE 

ADVANCEMENT OF SURGERY, 

THIS BOOK 

is 

Affectionately Dedicated 

BY 

THE AUTHOR. 



PREEACE TO THE THIRD EDITION. 



The second edition of this work, and the several reprints of it, 
were sold in so short a time after their publication that a revision 
seemed uncalled for; but the increasing literature and the introduc- 
tion of new remedies, methods of treatment, and improved instru- 
ments and apparatus render the time ripe for recasting much matter 
and introducing the new. 

Another chapter and many new articles and illustrations have 
been added, and wherever our present knowledge appeared to justify 
the omission of material to make room for more important matter 
it has been done. Several chapters have been condensed, and a num- 
ber of subjects have been wholly or partly rewritten, amplified, and 
illustrated. Recent discoveries and many helpful quotations and ref- 
erences to current literature have been added. Indeed, no effort has 
been spared to make this edition thoroughly representative of the 
most advanced work to the time of publication. 

Since by far the larger part of this volume is devoted to the nose 
and throat, it has been deemed advisable to indicate that fact by the 
present change in the title, according to which the division on the 
ear is placed last. More especially was this desirable in order that this 
book might not be confused with the writer's more complete work 
on "The Ear and its Diseases." 

American readers are so impatient of prolixity that the writer 
has not hesitated to sacrifice the euphony of diction to the utility of 
concise information. Especial care has been taken to represent the 
latest and most valuable work of Americans, as well as of foreign 
writers, for our own countrymen are too often overlooked, and their 
conscientious and meritorious labor meets with too little encourage- 
ment at home as well as abroad. Within the limited compass of this 
book the writer has endeavored to recognize merit wherever it was 
found — to be just toward all and generous toward his peers. 

The pleasant duty remains of expressing my sincere apprecia- 
tion of the generous adoption of this work, not only by the general 
practitioners, but by my fellow-teachers in a very large number of 
the medical colleges. I have earnestly striven to meet their require- 
ments and to merit their approval. 

S. S. B. 
103 State Street, Chicago. 

(vii) 



PREFACE TO THE SECOND EDITION. 



The early exhaustion of the first edition has afforded a welcome 
opportunity to add many desirable improvements in the second. The 
writer is under deep obligations for the cordial reception and generous 
criticism of the book by the medical press and profession. Many of 
the excellent suggestions made by the reviewers, who are largely 
teachers in this branch, have been acted upon, with the result of in- 
corporating new subjects and much other new and valuable material. 

The generally expressed wish for enlargement and greater detail 
in the treatment of various diseases has been met, as far as could con- 
sistently be done. Two new chapters have been written, one on "Re- 
lated Diseases of the Eye and Nose," and the other on "Life-insurance 
Affected by Diseases of the Ear, Nose, and Throat." Illustrated ar- 
ticles on "Direct Laryngoscopy, or Autoscopy"; and on "Pachydermia 
Laryngis," etc., have been added. Many new colored drawings and 
half-tone engravings from photographs of interesting and instructive 
cases, specimens, and preparations have been made for this edition. 

It was the original purpose to condense as much indispensable in- 
formation as possible in a book of convenient size for students and 
general practitioners, and it has been found practicable to hold to this 
method while making the additions of new matter, to the extent of 
more than 25 per centum, by utilizing to the highest advantage the 
arts of lithography, engraving, and printing. 

Instead of devoting the usual large space to descriptive anatomy, 
this subject is profusely pictured in close association with the diseases 
treated of, and the many illustrations, together with their accompany- 
ing explanations, keep the various organs, their surgical relations, 
and their varying appearances in health and disease always before the 
eye. It is believed that, with the more extended treatment of the 
most important subjects and their ample illustrations, this volume 
will meet with even a more cordial favor among the specialists than 
the first edition was fortunate enough to enjoy. 

For valuable services in preparing illustrations for the second 
edition the writer desires to express his acknowledgments and thanks 
to Professor Politzer for his permission to reproduce a number of his 
artistic colored figures; to Mr. Ready, the medical artist, for colored 

(ix) 



X PREFACE TO THE SECOND EDITION. 

drawings; to Max Thorner for illustrations of direct laryngoscopy; 
and to E. S. Talbot and C. W. Baker for photographs. 

Moved by the kind welcome accorded to the first edition, the 
writer has earnestly endeavored to make the second issue more fully 
and satisfactorily meet the requirements of a magnanimous profes- 
sion. 

S. S. B. 
103 State Street, Chicago. 



PKEFACE TO THE FIEST EDITION". 



Frequent requests from medical students and general practi- 
tioners for a book on diseases of the ear, nose, and throat especially 
adapted to their needs have prompted the writer to endeavor to meet 
this demand. 

This work was designed, first, to help students in preparing for 
their degree; second, for those progressive practitioners who wish to 
acquire the proficiency necessary to properly treat those patients who 
are unable to visit specialists; and, third, for those who are gradually 
exchanging their general practice for special work in these branches. 

The subjects are simplified and condensed so as to constitute this 
book a key, or introduction, to the exhaustive treatises already in the 
field. The place of the latter is not expected to be filled by this un- 
pretentious book, for it was not intended primarily for specialists. 
Yet it is hoped that it may modestly serve their interests in bringing 
information on the subjects down to the present date, and as a work 
of ready reference. 

Several subjects are treated in greater detail than characterizes 
the work as a whole, for the following reasons: ISTo book, equivalent 
to this, is now available containing the latest developments concern- 
ing diphtheria, the blood-serum therapy, the medical and surgical 
management of mastoid diseases, the related diseases of the eye and 
nose, the most successful treatment of hay fever, the improved com- 
pressed-air instruments, vaporizing apparatus, inhalents, etc. There- 
fore these subjects are given especial prominence. The opinions and 
experiences of a large number of eminent authorities are presented on 
the subjects of diphtheria, antitoxin therapy, and hay fever. 

Like works on general medicine and surgery, little space is de- 
voted to the anatomy of the various organs. It is assumed that the 
reader either has a fair understanding of anatomy or possesses such a 
book for reference. This fact, taken with the use of the descriptive 
illustrations, permits the devotion of most of our pages to diseases and 
their treatment. The new atlas of colored drawings by Professor 
Politzer is recommended as an aid in the study of middle-ear diseases. 

The writer has freely consulted many books and journals, and 
desires to fully and frankly acknowledge his very great indebtedness 

(xi) 



Xll PREFACE TO THE FIRST EDITION. 

to them. Chief among these are the works of Politzer (Dodd's 
translation). Sajous, Burnett, Gruber, Koosa, Browne, Mackenzie, 
Ingals, I>< (.-worth, Tuttle, the "American Year-book," etc. 

For generous contributions of valuable figures and plates I am 
under deep obligations to Politzer; Sajous; Truax, Greene & Com- 
pany; Holmes, and Krieger; and, for photographing, to F. A. Place. 
I am indebted, also, to my assistant, C. L. Enslee, for the laborious 
task of preparing the statistical table of 15,300 cases from my clinical 
record-books. 

It remains to express my sincere appreciation of the cordial co- 
operation, and the artistic execution of the publishers 7 important part 
in the work, by the F. A. Davis Company. 

The author indulges the hope that his labor may lighten the 
task of his readers in acquiring an understanding of the subjects 
taught. 

S. S. B. 
103 State Street, Chicago. 



C X T E X T S . 



PART I. 
DISEASES OF THE NOSE. 

CHAPTER I. 

FAGE 

Examination and Instruments 3 

Examination of patients. Instruments. Atomizers. Vaporizers. 
Sprays. Inhalents. Inhalers. 

CHAPTER II. 
Diseases of the Nasal Cavities 17 

Influenza. Acute rhinitis, or coryza. Simple chronic rhinitis. 
Chronic nasal catarrh. Cerebro-spinal rhinorrhcea. 

CHAPTER III. 

Diseases of the Nasal Cavities (Continued) 29 

Hay fever. The neurotic theory. Uric acid as a cause of hay 
fever. Predisposing and aggravating causes. 

CHAPTER IV. 

Diseases of the Nasal Cavities (Continued) 44 

Hay fever (continued). Symptomatology. Diagnosis. Prognosis. 
Abortive treatment. Local self-treatment. Preventive treat- 
ment. Hygienic measures. Symposium of medical opinions. 

CHAPTER V. 

Diseases of the Nasal Cavities (Continued) . . 57 

Hypertrophic rhinitis. Electrocautery apparatus. Surgical dy- 
namomotors. Operations for hypertrophies. The nose and the 
female sexual organs. Atrophic rhinitis, or dry catarrh. 
Ozeena. 

CHAPTER VI. 

Diseases of the Nasal Cavities (Continued) 76 

Epistaxis, or nose-bleeding. Mucous polypi. Fibrous polypi. Cys- 
tic polypi. Papillomata. Erectile tumors. Chondromata. 
Osteomata. Exostoses. Rhinoliths. Sarcomata. Carcinomata. 

CHAPTER VII. 

Diseases of the Nasal Cavities (Concluded) 8G 

Tuberculosis of the nose. Syphilis of the nose. Lupus of the nose. 
Glanders. Furunculosis. Anosmia. Parosmia. Deformities and 
diseases of the nasal septum. Blood-tumors of the nasal 
septum. Abscess of the septum. Perforation of the septum. 
Fractures of the nose. Congenital deformities of the nose. For- 
eign bodies in the nose. Animate objects in the nose. 

(xiii) 



XIV CONTEXT-. 

CHAPTER VIII. page 

Diseases oe the Accessory Caaities of the Xose 104 

Inflammation of the antrum of Highmore, or maxillary sinus. 
Ethmoid diseases. Sphenoid diseases. Diseases cf the frontal 
sinuses. 

CHAPTER IX. 
Related Diseases of the Eye axd Nose 116 

Diseases of the eye caused by nasal affections. Ocular reflexes 
from nasal diseases. Nasal diseases due to ocular anomalies. 

CHAPTER X. 

Diseases of the Xaso-pharyxgeal Cavity 128 

Xaso-pharyngeal catarrh. Atrophic catarrh of the naso-pharynx. 
Fibrous tumors of the naso-pharynx. Fibromucous polypi of 
the naso-pharynx. Malignant tumors. Adenoid vegetations in 
the vault of the pharynx. 



PAET II. 

DISEASES OF THE PHARYXX. 

CHAPTER XI. 
Diseases of the Phakyxx 147 

Acute pharyngitis, or simple sore throat. Simple chronic pharyn- 
gitis. Acute rheumatic pharyngitis. Chronic rheumatic sore 
throat. 

CHAPTER XII. 

Diseases of the Pharynx (Continued) 159 

Sore throat of measles, scarlet fever, and small-pox. Follicular 
pharyngitis. Membranous sore throat, non-diphtheric. 

CHAPTER XIII. 
Djskases of the Pharynx (Continued) 167 

Diphtheria. Pathology. Etiology. Symptomatology. Diagnosis. 
I *rognosis. 

CHAPTER XIV. 

Diseases oi mm Pharynx (Continued) 177 

Diphtheria (continued). Treatment. Examination of diphtheric 
p;it ients. [solation. Local and constitutional treatment. 

GHAPTEE XV. 

Diseases <h mm Pharynx (Continued) 187 

Diphtheria (concluded). Serum-therapy, or the antitoxin treat- 
ment of diphtheria. The production and action of antitoxin. 
The time and methods for using antitoxin. The dosage. The 
] esull - of blood serum t herapy. 



CONTENTS. XV 

CHAPTER XVI. P AGE 

Diseases of the Pharynx (Continued) 198 

Tonsillitis. Phlegmonous tonsillitis. Hypertrophy of the tonsils. 
Tonsillotomy. Instruments and methods of operating. Haemor- 
rhage following removal of the tonsils. The lingual, or fourth, 
tonsil. 

CHAPTER XVII. 

Diseases of the Pharynx (Continued) 214 

Mycosis, or parasitic disease of the pharynx. Concretions in the 
tonsil. Non-malignant tumors of the pharynx. Adhesions of 
the soft palate to the pharyngeal walls. Uvulitis. Bifid and 
double uvula s. Tuberculosis of the pharynx. Syphilis of the 
pharynx. Cancer of the pharynx. 

CHAPTER XVIII. 

Diseases of the Pharynx (Continued) 229 

Anomalies and new growths. Malformations and deformities. 
Stenosis. Dilatation. Papilloma. Cystoma. Carcinoma.- 
Fibroma. Lipoma. Angioma. Sarcoma. 

CHAPTER XIX. 

Diseases of the Pharynx (Concluded) 240 

Retropharyngeal abscess. Neuroses of the pharynx. Neuroses of 
sensation. Hyperesthesia. Anaesthesia. Paresthesia. Neu- 
ralgia. Neuroses of motion. Spasms of the pharynx. Globus 
hystericus. Pharyngeal chorea. Paralysis of the pharynx. 
Burns and scalds of the pharynx. Foreign bodies in the pharynx. 



PAET III. 

DISEASES OF THE LARYNX. 

CHAPTER XX. 

Diseases of the Larynx 251 

Indirect laryngoscopy. Instruments. Apparatus. Difficulties of 
laryngoscopy. Direct laryngoscopy, or autoscopy. 

CHAPTER XXI. 

Diseases of the Larynx (Continued) 261 

Acute laryngitis. 

CHAPTER XXII. 

Diseases of the Larynx (Continued) 267 

Croup. Comparison of true croup with laryngeal diphtheria. 

CHAPTER XXIII. 

Diseases of the Larynx (Continued) 273 

Intubation of the larynx. Instruments, method, and results. Care 
and feeding of patients. Tracheotomy. 



XVI CONTEXTS. 

CHAPTER XXIV. PAGE 

DrsEASES of the Laryxx (Continued) 283 

Chronic laryngitis. Atrophic laryngitis. Suppurative laryngitis. 
Abscess of the larynx. Trachoma of the vocal cords. (Edema 
of the larynx. 

CHAPTER XXV. 

Diseases of the Laryxx ( Continued) 290 

Xeuroses. Spasmodic croup. Anomalies of sensation. Nervous 
aphonia. Reflex affections of the voice. Paralyses. 

CHAPTER XXVI. 

Diseases of the Laryxx (Continued) 304 

Tuberculosis of the larynx. Syphilis of the larynx. 

CHAPTER XXVII. 

Diseases of the Laryxx (Concluded) 312 

Tumors. Innocent tumors. Papillomata. Fibromata. Pachyder- 
mia laryngis. Miscellaneous growths. Malignant tumors. Car- 
cinomata. Sarcomata. Foreign bodies in the larvnx. 



PABT IV. 

DISEASES OF THE EAR. 

CHAPTER XXVIII. 

A Gexeral Consideration of Diseases of the Ear. Nose, and 
Throat Based ox a Study of Twenty-one Thousand 
Cases 331 

Etiology. 

CHAPTER XXIX. 

Examination of Patients 338 

Instruments and apparatus. Tests for hearing. Recording cases. 
Forms for case-records. 

CHAPTER XXX. 

Compressed-air Appliances and their Uses 356 

Accurate methods of treatment with compressed air. High- and 
low- pressure devices. How to use high pressure safely. The 
advantages of improved air-condensers over rubber hag-. \)v- 
tails of treatment with air- meters, or regulators. 

CHAPTER XXXI. 

M it hods of Producing a.nd Using Compressed Air 363 

Useful devices for hand- and water- power pressure. Politzeriza- 
tion. Catheterization. Auscultation. 



CONTENTS XY11 

CHAPTER XXXII. PAGE 

Diseases of the External Ear . . . 375 

Frost-bite. Eczema. Lupus. Gangrene. Carcinoma. Perichon- 
dritis. Haematoma. Cystoma. Intertrigo. Herpes. Pemphigus. 
Syphilis. Deformities of the auricle. Hypertrophied auricle. 
Scroll-ear and associated deformities. 

CHAPTER XXXIII. 
Diseases of the External Auditory Canal 384 

Inspissated and impacted cerumen. Diffuse inflammation of the 
external meatus. Furunculosis. Parasitic inflammation, or 
otomycosis. Exostoses. Imperforate meatus. Foreign bodies 
in the meatus. 

CHAPTER XXXIV. 

Diseases of the Middle Ear 39G 

Injuries to the drumhead. Inflammation of the drumhead. Eu- 
stachian tubal catarrh, or salpingitis. Acute inflammation of 
the middle ear. 

CHAPTER XXXV. 

Diseases of the Middle Ear (Continued) 407 

Acute suppurative inflammation of the middle ear. Chronic non- 
suppurative inflammation of the middle ear. Hypertrophic, or 
secretive, catarrh of the middle ear. 

CHAPTER XXXVI. 

Diseases of the Middle Ear (Continued) 418. 

Adhesive inflammation of the middle ear. 

CHAPTER XXXVII. 

Diseases of the Middle Ear (Continued) 433 

Operative treatment of tympanic adhesive inflammation. Mobil- 
ization of the ossicles. Incision of the posterior fold of the 
drumhead. Multiple incisions of the drumhead. Excision of 
areas of the drumhead. Division of the tensor tympani. Ex- 
cision of the membrana tympani and ossicles. Operation for 
excision of the ossicles. Mobilization of the stirrup. Stapedec- 
tomy. 

CHAPTER XXXVIII. 

Diseases of the Middle Ear (Continued) 445 

Chronic suppurative inflammation of the middle ear. Aspiration 
of the tympanic cavity. 

CHAPTER XXXIX. 

Diseases of the Middle Ear (Concluded) 456 

Sequels of middle-ear inflammation. Granulations. Polypi. 
Caries and necrosis of the tympanic cavity. Necrosis of the 
ossicles. Adhesions, cicatrices, and perforations of the mem- 
brana tympani. Artificial drumheads. Deafness following- 
suppuration. Tinnitus in purulent inflammation. Choleste- 
atoma. Facial-nerve paresis and paralysis. Carious processes 
in the temporal bone. Haemorrhage. Pyaemia. Sequestra. 



XV111 CONTENTS. 

CHAPTER XL. 

PAGE 

Extension of Ear Diseases to the Cranial Cavity 472 

Meningitis. Extradural abscess. Cerebral abscess. Cerebellar ab- 
scess. Operations for brain-abscesses. Sinus-phlebitis and 
sinus- thrombosis. 

CHAPTER XLI. 

Diseases of the Mastoid Process . 479 

Medical treatment. Surgical treatment. Indications and prep- 
arations for mastoid operations. Preparation of patient. In- 
struments required. Preparation of instruments. 

CHAPTER XLII. 

The Mastoid Operations 492 

The Schwartz operation. The radical tympano-mastoid, or Stacke, 
operation. The modified mastoid operation. Abscess of the 
neck from middle-ear and mastoid suppuration. 

CHAPTER XLIII. 

Diseases of the Internal Ear 514 

Hyperemia and anaemia of the labyrinth. Inflammation of the 
labyrinth. Panotitis. Haemorrhage into the labyrinth. Meni- 
ere's disease. Leucocythsemic deafness. Syphilis of the laby- 
rinth. Diseases of the auditory nerve. Neuroses of the per- 
ceptive apparatus. Hyperaudition. Hyperesthesia. Paracusis. 
Paracusis Willisii. Subjective sounds, or tinnitus aurium. 
Nervous tinnitus. Spasmodic noises. Paresis and paralysis of 
the auditory nerve. Cerebral causes of deafness. New growths 
of the internal ear. 

CHAPTER XLIV. 

Diseases of the Internal Ear (Concluded) 525 

Injuries to the labyrinth. Deaf-mutism. Education of the deaf. 



Hearing-instruments. 



CHAPTER XLV. 



Life-insurance Affected by Diseases of the Ear, Nose, and 

Throat 533 

APPENDIX. 
Remedies 539 

Index 549 



LIST OF ILLUSTRATIONS. 



FIG. PAGE 

1. Convenient Arrangement for Treatment Room 2 

2. Electric Illuminator,, as Used in Posterior Rhinoscopy 3 

3. Nasal Speculum of Correct Pattern, and the Proper Way to 

Handle it 4 

4. Bosworth's Tongue-depressor 5 

5. Throat-mirrors 5 

6. White's Palate-holder. 6 

7. Sajous's Soft-palate Elevator 6 

8. The Posterior Rhinoscopic Image 7 

9. The Davidson Spray-producers 8 

10. The De Yilbiss Atomizer 9 

11. The Lavolin Atomizer 9 

12. Truax, Greene & Company's Atomizer 10 

13. Andrews's Combined Atomizer and Vaporizer 10 

14. The Globe Vaporizer 11 

15. The Globe Nebulizer 12 

16 to 21. Methods of Receiving Sprays and Inhalents 12 

22. Hot-water Inhaler 15 

23. The Author's Camphor-menthol Inhaler 15 

24. The Author's Soft-rubber Nasal Bougie 26 

25. Nasal Synechia 57 

26. Posterior View of Osseous Bridge Shown in Fig. 25 5S 

27. Transverse Vertical Section through the Vault of the Pharynx and 

Eustachian Tubes 59 

28. Transverse Vertical Section through the Posterior Nares 60 

29. Transverse Vertical Section through the Orbits, Nasal Fossse, and 

Maxillary Antra 61 

30. Transverse Vertical Section through the Nasal Fossae 62 

31. The Wabash Cautery Battery, with Electrodes, Lamp, and Handles. 63 

32. The American Storage Battery 64 

33. Electric-current Transformer and Dynamomotor 65 

34. Alternating Electric-current Transformer for Cautery Purposes.... 66 

35. Cautery-knife 67 

36. Mcintosh Electrocautery Handle, with Snare and Windlass 67 

37. Hobby's Steel Snare 69 

38. The Author's Septum-knife 70 

39. Electric Drills 70 

40. Electric Trephines 71 

41. The Author's Nasal Saws 71 

42. Bellocq's Cannula Introduced 77 

43. Curette-forceps 78 

44. Very Strong Cutting Forceps 79 

45. Casselberry's Saw-tooth Scissors 80 

46. Fragments of a Rhinolith, Exact Size, Weighing Seventy-one 

Grains, from a Woman Fifty-nine Years Old 83 

47. Destruction of the Hard Palate, the Soft Palate Remaining Un- 

harmed 84 

48. Destruction of the Bones Forming and Supporting the Bridge of the 

Nose 87 

49. Partial Destruction of the Bones of the Nose, Resulting in Two Per- 

forations SS 



(xix) 



XX LIST OF ILLUSTRATIONS. 

FIG. PAGE 

50. The Author's Nasal Supporter • 89 

51. Moderate Deflection of the Septum Nasi 04 

~vl. Deflection of Septum Nasi Sufficient to Cause Stenosis of the Left 

Na lis 95 

53. Deflection of Septum Nasi toward the Right Side, at nearly a Right 

Angle 93 

54. Deflection of Septum Nasi toward the Left Side with Apparent, but 

not Real, Adhesion to the Left Inferior Turbinated Body 97 

55. Perpendicular Portion of the Ethmoid Bone, consisting of Two 

Plates; the Inferior Turbinated Bone of the Left Side is Plainly 

Visible 98 

56. Transverse .Vertical Section through the Nasal Fossae 99 

57. Transverse Vertical Section through the Nasal Cavities 100 

58. Hartmann's Forceps 102 

59. Transverse Vertical Section through the Nasal Fossae and Max- 

illary Antra 104 

00. Transverse Vertical Section of the Nasal Fossae 105 

61. Transverse Vertical Section through the Maxillary Antra 100 

62. Transverse Vertical Section through the Maxillary Antra 107 

63. Cannula and Trochar . . . * 108 

64. The Author's Antrum and Ethmoid Irrigator 109 

05. Longitudinal Vertical Section (Actual Size) through the Nasal and 

Accessory Cavities Ill 

00. Longitudinal Vertical Section (Natural Size) through the Nasal 

and Accessory Cavities 113 

07. Dissection showing Nasal Duct and its Relations 117 

68. Ducts Connecting the Nose with the Accessory Sinuses and the Eye 119 

09. Lacrymal Knife 124 

70. Contracted Upper Jaw ; Narrow Roof of Mouth with very High 

Arch, Encroaching upon the Nasal Fossae 135 

71. A Mouth-breather 137 

72. Denhart's Mouth-gag 138 

73. Position of Child for Adenoid Operation or Intubation ; Mouth-gas 

Introduced ' 139 

74. Cottstein's Ring-curette 140 

75. Diphtheria Bacilli 168 

70. Diphtheria Bacilli 169 

77. Streptococcus Pyogenes 170 

78. The Author's Tonsillotome, with Excised Tonsil 207 

79. Bifid Uvula in a Man Sixty Years Old 216 

80. Complete Double Uvula in a Boy of Fourteen Years 218 

81. Large Perforation of the Velum Palati 223 

82. Desi ruction of the Velum Palati 225 

83. Small Powder-blower with Long Tube 227 

84. Stenosis of the Pnarynx 230 

85. Mackenzie's Lateral Throat-forceps 246 

86. De Vilbiss Illuminator 252 

87. Tin 1 Author's Epiglottis Retractor 255 

Position for Autoscopy 256 

89. Tongue-depressor for Pharyngoscopy and Direct Laryngo-tracheos- 

popy 257 

90. Tangential Plane 2.~>7 

91. Standard Spatulas 258 

92. Types of Instruments for Autoscopic Operations 259 

93. O'Dwyer's [ntubation-tubes 273 

94. Scale 273 

95. <)' I )\\ y civ I nt roducer, with Tube Attached 274 

96. O'Dwyer's Extractor 275 

97. Roswell Park's Aluminium Tracheal Tube 279 



LIST OF ILLUSTRATIONS. XXI 

FIG. PAGE 

98 Hard-rubber Tracheal Tube 280 

90. Tracheal Dilator 281 

100. The Author's Medium Laryngeal Applicator 288 

101. The Author's Long Laryngeal Applicator 289 

102. Tobold's Set of Six Forceps. Knives, etc 314 

103. The Author's Long Antero-posterior Laryngeal Forceps with Biting- 

Edges 315 

104. Laryngeal Papillomata ■ 316 

105. Laryngeal Papillomata 317 

106. Laryngeal Papillomata 317 

107. The Author's Long Lateral Laryngeal Forceps with Biting Edges. . 319 

108. The Author's Laryngeal Cautery Electrode 321 

109. The Author's Light-reflector and Screen 338 

110. Spring-band Mirror-holder 339 

111. The Author's Adjustable Bracket 340 

112. The Author's Ear-specula . 341 

113. Gruber's Ear-specula 341 

114. The Author's Massage Otoscope 342 

115. The Author's Cotton-carrier 343 

116. Normal Drumhead of Bight Ear 344 

117. Normal Drumhead of Left Ear ■. 344 

118. Outer Surface of the Left Tympanic Membrane of an Adult 345 

119. The Author's Automatic Tuning-fork 347 

120. Hartmann's Tuning-forks 348 

121. Galton's Whistle . 350 

122. Politzer's Acoumeter 351 

123. The Author's Original Compressed-air Meter 357 

124. The Author's Cut-off 358 

125. Vaporizers and Combined Air-reservoir and Hand-pump 304 

126. Compound Hydraulic Pump beneath the Water-basin 365 

127. Single-acting Hydraulic Pump • 366 

128. Rotary Air-pump 367 

129. Globe Double-cylinder Air-pump 368 

130. Air-meter of Improved Pattern 369 

131. Globe Compressed-air Apparatus 370 

132. Buttle's Inflator 370 

133. Politzer's Airbag 371 

134. The Author's Improved Inflator 371 

135. Eustachian Catheter 372 

136. Vertical Section of the Xaso-pharynx with the Catheter Introduced 

' into the Eustachian Tube 372 

137. Fixation of the Catheter with the Left Hand 373 

138. Toynbee's Auscultation-tube 373 

139. Gangrene of the Ear; Mastoid Operation 377 

140. Hypertrophied Auricle 381 

141. Lever and Handle 384 

142. Hard-rubber Syringe 3S5 

143. Alpha Syringe' 386 

144. Author's Small Powder-blower for the Ear 389 

145. Ear-forceps 394 

146. Rupture of the Antero-inferior Segment of the Drumhead Caused 

by a Box on the Ear 396 

147. Section through the Tympanic Membrane. Malleus, and Upper and 

Outer Tympanic Wall of a Decalcified Preparation 397 

148. Eustachian Tube and Tympanic Cavity 399 

149. Radiate Vascular Injection of the Drumhead 403 

150. Radiate Vascular Appearance in Acute Inflammation of the Middle 

Ear 404 

151. Convexity of the Drumhead Due to Pressure from Within 407 



XX 11 LIST OF ILLUSTRATION'S. 

FIG. PAGE 

152. Nipple-shaped Bulging of the Posterior Portion of the Drumhead, 

on the Summit of which is the Perforation 410 

153. Fluid Effusion in the Tympanic Cavity, Marked by a Bright Line. . 411 

154. Circumscribed Bulging of the Drumhead. Due to Pressure of Fluid 

in the Middle Ear ' 412 

155. Great Concavity of the Drumhead and Foreshortening of the Ham- 

mer-handle 413 

156. Semilunar Chalky Deposit in Front of the Handle of the Mallet. . . 419 

157. Niche of the Fenestra Ovalis, with the Crura of the Stapes, in the 

Normal Ear of an Adult 420 

158. Marked Retraction of the Drumhead 424 

159. Circumscribed Depressions in the Anteroinferior Quadrant of the 

Left Drumhead 425 

1G0. Circumscribed Adhesion of the Membrana Tvmpani to the Promon- 
tory Underneath the Handle of the Mallet 426 

161. The Intratympanic Masseur 427 

162. Lucse's Pressure-probe 428 

163. The Author's Ossicle-vibrator 433 

164. Section of the Posterior Fold of the Membrana Tvmpani 434 

165. Internal Surface of the Left Membrana Tympahi 435 

166. Triangular Resection of the Drumhead 436 

167. Middle-ear Instruments and Handle 440 

168. The Author's Ossicle-hook 440 

169. Politzer's Pincette , 441 

170. Vertical Section of the External Meatus, Membrana Tvmpani, and 

Tympanic Cavity 442 

171 . Extensive Destruction of the Drumhead 445 

172. Pear-shaped Perforation of the Drumhead 446 

173. Perforation of the Posterior Half of the Right Drumhead 446 

174. Destruction of the Inferior Half of the Membrana Tvmpani, laying 

Bare the Promontory and Niche of the Round Window 447 

175. Large Perforation of the Right Drumhead 447 

176. Destruction of Inferior Half of the Drumhead 449 

177. Slender Middle-ear Probe 450 

178. The Author's Large Powder-blower for Use with a Hand-bulb or 

Compressed Air 451 

179. The Author's Ear-aspirator 454 

180. Politzer's Polypus-forceps 457 

181. The Author's Middle-ear Case 458 

182. The Author's Caustic Applicator on Flexible Shank 47)H 

183. Vertical Section of Middle Ear; Drumhead in Contact with the 

Inner \\ all 459 

184. Band-like Cords between the Lower End of the Hammer-handle and 

1 he Stapedo-incudal Articulation 460 

1S5. Central Perforation of the Drumhead and Calcareous Deposits.... 4til 

1 86. Facial Paresis 464 

187. Same as Fig. 186, Three Months after Stacke Operation and Treat- 

ment wilh Electricity 465 

The Am hor's Ear-electrodes, Attached to a Head-band 466 

L89. Sequestra of Dead Bone, and the Ossicles. Actual Size 468 

190. Post-mortem SectioD of the Temporal Bone, showing a Perforation 

of the Lateral (Sigmoid) sinus 4<i'.» 

191. The Author's Middle ear Curette 47o 

192. Horizontal Section of the Ear 47" » 

193. tnterior of Base of skull 480 

L94. The \m hor's tcebag 

L95. Buck's Mastoid Knife 485 

196. The Nevius Electric Mead lamp 

197. A Strong Scalpel ". 486 



LIST OF COLORED PLATES. XXlii 

FIG. PAGE 

198. The Author's Mastoid Chisel. Actual Width 487 

199. The Author's Long Mastoid Gouges. Actual Width 487 

200. Lead-filled Mallet 488 

201. The Author's Set of Curettes 488 

202. The Author's Mastoid Guide. 489 

203. Mathieu's Tongue-holding Forceps 489 

204. The Author's Periosteum Elevator 490 

205. The Author's Self -retaining Retractors 490 

206. A Mastoid Operation 493 

207. Operating-room and Accessories 494 

208. Horizontal Section through Eight Temporal Bone, cut Two Milli- 

metres above the Centre of the External Canal 495 

209. Side-view of a Skull, showing Opening in Mastoid Process for 

Schwartze Operation 496 

210. Schwartze Operation 497 

211. Opening of the Antrum 498 

212. Horizontal Section through Right Temporal Bone, showing Dis- 

tance between Lateral Sinus and External Canal 499 

213. Horizontal Section through Right Temporal Bone, cut near Centre 

of External Meatus, showing how Close the Lateral Sinus may 

Come to the External Canal in some Cases 499 

214. Perpendicular Section through the Right Temporal Bone 500 

215. Adhesive-plaster Dressing for Mastoid Wound 501 

216. Line of Incision Healed Two Months after Schwartze Operation.. . 501 

217. The Radical Tympano-mastoid (Stacke) Operation, Completed 502 

218. Side of Skull, showing Stacke Operation 503 

219. Vertical Section through the Ear 504 

220. Section of the Temporal Bone. Actual Size Facing 504 

221. Section of the Temporal Bone. Natural Size Facing 504 

222. Horizontal Section of Temporal Bone, cut near Floor of External 

Meatus 505 

223. Six Weeks after Stacke Operation 506 

224. Appearance Two Weeks after the Modified Operation 507 

225. Post-mortem Section of Mastoid Process. 508 

226. Appearance Three Weeks after a Modified Stacke and an Operation 

for a Neck-abscess 509 

227. Abscess of the Mastoid Process Extending over Ten Weeks, Result- 

ing in an Enormous Abscess of the Neck, Reaching Nearly to 

the Thoracic Cavity 510 

228. The same as Fig. 227, showing the Outline of the Swelling 511 

229. The Conical Conversation-tube 529 

230. The London Horn 530 



LIST OF COLORED PLATES. 



PLATE PAGE 

I. Vertical Antero-posterior Section of the Nasal Cavities, Mouth, 

Pharynx, and Larynx Facing 6 

II. Various Diseases of the Nasal Cavities Facing 24 

III. Various Diseases of the Nasal Cavities, Palate, Uvula, and 

Tonsils Facing 56 

IV. Diseases of the Nose and Pharynx and Anatomy of the Nose, 

Pharynx, and Larynx Facing 147 

V. Anatomy of the Larynx Facing 251 

VI. Various Diseases of the Larynx Facing 282 

VII. Various Diseases of the Larynx Facing 312 

VIII. Various Diseases of the Ear Facing 396 



PART I. 



Diseases of the Nose. 



(i) 




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(2) 



CHAPTER I. 
DISEASES OF THE NOSE. 

Examination and Instruments. 

Rhinological practice requires an illuminating apparatus like 
the one shown in Fig. Ill, or the electric forehead-lamp, or a student- 
lamp. Fig. 2 shows an electric light attachable to a portable bat- 
tery. It consists of a telescoping cylinder from one and one-half to 




Fig. 2. — Electric Illuminator, as Used in Posterior Rhinoscopy. 

two inches (four to five centimetres) long, and is five-eighths of an 
inch (sixteen millimetres) in diameter, provided with two powerful 
lenses. This instrument, when lighted, throws a white light of six- 
to eight- candle power directly upon the object in the focus. This 
illuminator is particularly adapted to the wants of the specialist. By 
removing it from the head-band it may be used as a hand-illuminator 
in examining other cavities of the body. The examiner should sit 
sidewise by the patient, immediately in front and facing him, using 
the three-inch forehead-mirror, which is shown in Fig. 110. Reflected 

(3) 



4 EXAMINATION" AND INSTRUMENTS. 

light only can be used to advantage in this practice. The surgeon 
should wear the mirror in front of his eye so as to look through the 
perforation in the glass, and in such a manner as to shade both eyes 
from the light. The room is best darkened in order to avoid the con- 
tracting effect of the light on the pupils of the surgeon's eyes. 

A convenient arrangement of a treatment-room is illustrated in 
Fig. 1. It shows, in a compact space, an adjustable gas-lamp, fitted 
with a light-reflector; electric lamps; compressed-air regulators, with 
two treatment tubes and cut-offs attached; nebulizers and sprays; a 
dynamomotor, which transforms the electric current for cautery pur- 
poses and operates the dental arm for trephines, drills, etc.; and the 
Pynchon cabinet for instruments, medicines, linen, etc. 




Fig. 3. — Nasal Speculum of Correct Pattern, and the Proper Way 

to Handle it. 



During the examination of the nose, one hand of the operator 
should rest on the top of the patient's head so as to control and 
manipulate its movements as is necessary in order to bring all the 
parts to be examined into the field of vision. 

The instruments required for anterior rhinoscopy are a nasal 
speculum (Fig. 3), a long cotton-carrier (Fig. 115) to remove secre- 
tions thai obstruct a view of the parts, and a bent long probe for 
searching oul hyperaesthetic areas and determining the contour and 
i in of anomali 

The nasal speculum is best held in the palm of the hand with 
the back of the fingers directed toward the patient's chin. The handle 



ANTERIOR RHINOSCOPY. 5 

of the speculum should project straight outward and downward from 
the bivalves, so as to leave sufficient room between the patient's chin 
and the surgeon's ringers. The valves should be small enough at 
their tip to use with children. In manipulating the speculum the 
pressure ought to be exerted mainly on the soft, yielding ala of the 
nose, and not on the septum. De Vilbiss has devised an excellent 




Fig. 4. — Bosworth's Tongue-depressor. 

self-retaining nostril-dilator to be held in place by a rubber band 
about the head. 

Anterior rhinoscopy, or the examination of the anterior nares, 
reveals the anterior extremities of the turbinated bodies and the side 
of the septum. The patient's head is tilted backward or forward, as 
the upper or lower parts of the nasal cavities are to be inspected. 




«W 



In many instances we can obtain a clear view entirely through the 
nose to the vault and posterior wall of the pharynx. In others, hy- 
pertrophies of the turbinated bodies or of the septum or deflections 
of the latter occlude the view. 

In health the color of the mucous membrane covering the lower 
portions of the fossa is a light pink; that of the superior turbinated 



6 POSTERIOR RHINOSCOPY. 

body and roof of the nasal arch is yellowish. The nature of the light 
furnishing the illumination may vary the shade considerably. 

Posterior rhinoscopy calls for the use of a tongue-depressor (Fig. 
4), rhinoscopic mirrors (Fig. 5), and occasionally a palate-retractor 
(Fig. 6). The tongue-depressor should not be inserted far enough to 
cause retching, and the patient is told not to resist the gentle pressure 
and not to gag. His co-operation aids materially in the examination, 
and only a little practice is necessary to success. When the rhinoscopic 
mirror is introduced, the tongue-depressor is held by the left hand and 




Fig. 6.— White's Palate-holder. 

the mirror by the right. Just before introducing the mirror it is 
warmed by passing it with the glass side downward over the lamp for 
an instant only, to avoid the condensation of the patient's breath on 
it, which would prevent a reflection of the post-nasal image. If the 
mirror is too greatly heated its backing is destroyed. Another method, 
which the author has employed satisfactorily for a considerable time, 
is to cover the glass surface of the mirror with liquid soap, and then 
polish it with a dry cloth. This soft soap prevents the breath from 




Fig. 7. — Sajous's Soft-palate Elevator. 



condensing on the glass, and renders the use of heat unnecessary. I 
have used Lee's liquid soap for this purpose. 

With the light reflected into the throat by the forehead-mirror, 
the nasal mirror is carried over the depressed tongue until it nearly, 
but not quite, touches the posterior pharyngeal wall with the mirror- 
surface directed upward and forward (Fig. 8). The natural inclina- 
tion is to breathe through the mouth when it is open, and the patient 
is directed to breathe through his nose so that the soft palate will 
fall forward and downward from contact with the post-pharyngeal 
wall. Then, with the light properly directed upon the mirror, an 



PLATE I; 



PLATE T. 



Vertical antero-posterior section of the nasal cavities, mouth, pharynx, and 
larynx. 

1. Frontal sinuses. 

2. Superior turbinated body. 

3. Sphenoid sinuses. 

4. Middle turbinated body with posterior hypertrophy. 
5." Adenoid growths. 

G. Inferior turbinated body. 

7. Orifice of the Eustachian tube. 

8. Fossa of Rosenmiiller. 

9. Oral tonsil. 

10. Epiglottis. 

11. Vocal cord. 

12. Trachea. 

The mirror and line of reflected light illustrate laryngoscopy. 



FLUTE I. 




POSTERIOR RHINOSCOPY. 7 

image of the posterior riares should be seen. If the palate still em- 
barrasses the view, it can be lifted and drawn slightly forward by 
the palate-elevator (Figs. 6 and 7). Painting the uvula and velum 
with a 4-per-cent. solution of cocaine or eucaine will facilitate this 
procedure. The Sajous elevator is convenient. It is placed so as to 
lift the uvula with the soft palate, and the handle is held a little to 
one side, so as not to obstruct the field of vision. 




The Posterior Rhinoscopic Image. (After Bosworth.) 



As large a mirror should be used as the space will permit (one- 
half to three-fourths of an inch — thirteen to nineteen millimetres), 
but it must be small enough not to necessarily come in contact with 
the surrounding parts and produce gagging. The mirror is so manip- 
ulated as to bring the plane of its surface at an angle of about sixty 
degrees to the perpendicular plane of the posterior nares, in order to 
obtain a perfect image. 



s 



SPRAY-PRODUCERS. 



The first reflected image to. attract the attention is that of the 
velum palati. By slightly changing the position of the mirror, the 
septum on the one side and the orifice of the Eustachian tube on 
the other come prominently into view, with the posterior ends of the 
turbinate bodies in the centre of the field. The two lower ones, of 
a light-pink hue, are easily distinguished; but the superior body, 
yellowish and dimly outlined in its remote recess, is not so easily seen. 

The vault of the pharynx is rendered visible by tilting upward 
the mirror-handle in varying degrees until one obtains an image of 
the pharyngeal tonsil. It is often necessary to cleanse the nasal pas- 




Fig. 9. — The Davidson Spray-producers. 

sages with the detergent solutions before a complete inspection can 
be made. 

The Davidson atomizers (Fig. 9) are very convenient for cleansing 
and medicating the nares. They throw a very coarse spray, bathing 
the parts profusely. They hold a large amount of fluid, do not leak, 
;iii(] arc supplied with both straight and curved tips for the naso- 
pharynx and larynx. The De Vilbiss atomizer (Fig. 10) lias an ex- 
cellenl adjustable tip. It can be turned so as to throw the spray 
in any direction desired, from the posterior nares to the larynx. His 
latesl device t<» be used with compressed air has a flange upon which 



ATOMIZERS. 



tlie fingers rest to prevent the column of air from throwing the instru- 
ment out of the grasp. It is made with a broad base so as to prevent 
it from tipping over, and it can be used with the hand-bulb also. The 
lavolin atomizers (Figs. 11 and 12) are very convenient for home 
treatment. We often prescribe these with a 3-per-cent. solution of 
camphor-menthol in lavolin or benzoinol for patients to use at bed- 




Fig. 10. — The De Vilbiss Atomizer. 



time, -to aid in the treatment. By this means they keep the upper 
respiratory passages cleansed and protected and they are more faithful 
to the treatment. The results are more satisfactory with this method. 
My assistant, A. H. Andrews, has devised an excellent atomizer 
which will produce both coarse sprays and tine vapors, and it can be 
operated by a rubber bulb or by the compressed-air apparatus (Fig. 13). 




The Lavolin Atomizer. 



Many devices are employed for treating the nasal cavities, but 
few are necessary. Some are capable of doing actual harm. The 
Weber nasal douche has thrown watery solutions through the Eusta- 
chian tubes into the middle ears, setting up an inflammation. This 
is especially liable to happen when any stream of fluid is passed into 
the nostril, for there is a strong inclination to swallow, provoked by 



10 



ATOMIZERS AND VAPORIZERS. 



the presence of the liquid. In the act of deglutition the orifices of 
the tubes open and allow the entrance of the fluid into the tympanic 
cavities. One of the most useful instruments for medicating the re- 




Fig. 12.- — Truax, Greene & Company's Atomizer. 

spiratory passages, after they are properly cleansed, is shown in Fig. 
14. It consists of a nebulizer which projects the most finely dif- 
fused spray obtainable, and admits of the use of much stronger 




Fig. 13. — Andrews's Combined Atomizer and Vaporizer. With the nasal 

tip lightly adjusted a fine vapor is produced; with the tip firmly 

pressed upon the spray-tube, a coarse spray results. 

medicaments than are ordinarily used. It is so constructed that the 
medicament from one of the nebulizing globes can be propelled 
into the nose, throat, or middle ear in a steady current, or with in- 
terrupted currents by tapping on Valve I. Or- the inhalents in 



VAPORIZERS. 11 

two or all of the nebulizing globes can be combined and used at the 
same instant. 

An important addition to this vaporizer is the air-regulating 
collar below Push-button I. By this device the amount of pres- 
sure is easily controlled and shut off altogether, if desired, when the 
interrupted current is employed for inflating the middle ears. 

The compressed air is supplied to Circular Tube H by means 
of attaching the cut-off of the air-reservoir to it. The air is admitted 
to the globes by opening the keys at G. 

For those practitioners who are not supplied with a compressed- 
air apparatus the Globe nebulizer (Fig. 15) is an excellent substitute 
for the large vaporizer. It is also fitted for use with compressed air 
and is employed in the same manner as the vaporizer. Fig. 16 repre- 
sents an inhalation taken . through the aseptible face-mask. Fig. 

auge 

Ma ss a_ge Ifj/veT 
' PiJ,eS 




Fig. 14. — The Globe Vaporizer. 

17 shows the inhalation through a small vulcanite mouth-tube, and 
in Fig. 18 the returning medicated vapor is seen to issue from both 
nostrils. Figs. 19 and 20 illustrate the medication of the nasal pas- 
sages and vault of the pharjmx by permitting the vapor to enter one 
nostril and return through the other or through the mouth. In Fig. 
21 the opposite naris is closed while the vapor is made to inflate the 
middle ears. 

With such perfect instruments as are here shown, and with suffi- 
cient air-pressure, the most effective treatment is rendered possible 
with accuracy and ease. Homer M. Thomas has demonstrated by 
experiments in Cook County Hospital that a vaporized medicament 
penetrates into the pulmonary alveoli of the human lung. He writes: 
"I have repeatedly seen good results in the treatment of localized in- 
flammations of the bronchial tract, by inhalation, as far as the second 



12 



SPRAYS AND INHALENTS. 



division of the bronchi. I have obtained results in that way that I 
have repeatedly failed to secure with internal medication. It is sur- 
prising how the respiratory ability can be increased by a little in- 
struction and effort." (The Laryngoscope, November, 1897.) 




Fig. 15.— The Globe Nebulizer. 

Sprays and Inhalents. 

I have devoted considerable time to the investigation of inhalents, 
and have endeavored to arrive at definite results. We know well the 
action of nitrate of silver or sulphate of zinc when applied to mu- 
cous membranes, but accurate studies have not been sufficiently de- 






Fig. 16. 



Fig. 17. 



Fig. 18. 





Fig. 19. 



Fig. 20. 




voted to the physiological actions of the large number of inhalents- 
offered for our use. 

These actions should be determined before we apply a local 
remedy to a <li-<;i>c(l surface, for the same reasons- that no internal 



SPKAYS AXD IXHALEXTS, 13 

medicine should be administered without fulfilling a special indica- 
tion for its use. 

In the case of camphor-menthol we have no doubt as to its place 
in therapeutics. We have defined its actions: It contracts the capil- 
lary blood-vessels of the mucous membrane, reduces the swelling; 
relieves pain and fullness of the head, or stenosis; arrests sneezing, 
checks excessive discharges, and corrects perverted secretions. We 
know, also, that it possesses antiseptic qualities. 

Since my introduction of this remedy at the meeting of the Mis- 
sissippi Valley Medical Association, in 1891, it has come into quite 
general use for catarrhal conditions of the upper respiratory tract. 

Although the author did not recommend it until long after he 
had discovered that the union of these two camphors resulted in a 
fluid of the chemical formula C 10 H ls O, and after becoming satisfied 
that we possessed a valuable remedy in this new drug, he is now able 
to express greater confidence, and to verify former statements by the 
experience of others as well as by the daily use of it up to the present 
time. The experimental stage has passed and the efficacy of this 
remedy is clearly established. Specialists who were at first skeptical 
as to its virtue have since adopted it as a standard remedy in both 
private and dispensary practice. I have taken pains to ascertain the 
results of their experiences, and add them to my own. 

Pure camphor-menthol is the product resulting from bringing 
together equal parts of gum-camphor and menthol crystals without 
heat. They soon form a colorless liquid by uniting in nearly equal 
parts. This pure camphor-menthol is used in combination with 
lavolin or benzoinol in various strengths for producing sprays and 
vapors. Lavolin is a purified, colorless, petroleum-oil. Benzoinol is 
a similar oil, with the addition of'benzoin. 

The field of application in which camphor-menthol has proved 
most efficacious is in the following diseases: Coryza, hay fever, in- 
tumescent rhinitis (intermittent and alternating nasal stenosis), hy- 
pertrophic rhinitis, simple sore throat, acute laryngitis, tracheitis, 
bronchitis, and after nasal cauterization. 

For home use and ordinary office treatment we do not employ 
a stronger solution than the 3 per cent, in lavolin or benzoinol, and 
for very sensitive cases, like hay-fever sufferers, the 1- or 2-per-cent. 
solution at first. The lavolin is a bland and soothing protective to 
the membrane, and in the combinations indicated we have a most 
effective and harmless remedy. This means a great deal to both pa- 



14 SPRAYS AXD INHALENTS. 

tient and physician, for many of the sprays in use give indifferent 
results — or worse. 

Patients should be instructed to treat themselves thoroughly 
every night on retiring, by throwing a spray of the 3-per-cent. solu- 
tion from an atomizer (Fig. 11) into both nostrils while slowly in- 
haling. The rubber bulb should be forcibly and rapidly compressed 
at least eight times for each nostril. For the throat, larynx, or bron- 
chial tubes the spray should be thrown through the mouth during 
inhalation. 

In diphtheria, croup, etc., in infants, when it is very difficult to 
throw a spray into the throat, the medicine may be made to reach the 
parts in a volatile form by placing a few drops of the pure, undiluted 
camphor-menthol in a hot-water inhaler (Fig. 22) or a tea-kettle of 
hot water and causing the patient to breathe the medicated steam; or 
a few drops can be heated in a spoon over a lamp, and its fumes will 
impregnate all the atmosphere of the room. Enough medicine need 
not be used to cause uncomfortable smarting of the eyes. Inflamma- 
tion of the throat, larynx, trachea, and bronchi can be effectually 
treated by inhaling the camphor-menthol steam in this manner. 

The writer has found that we can prevent haemorrhage and in- 
flammation, following galvano-cauterization of the turbinated bodies, 
by gently packing a pledget of cotton wet with a 10-per-cent. solution 
of the camphor-menthol between the burned tissue and the septum 
and leaving it there twenty-four or forty-eight hours. It is then re- 
placed by a fresh dressing, and, at the end of four or five days, instead 
of finding sloughs filling the passages, swelling, and stenosis, the tis- 
sues appear shrunken and mummified and the strait is clear. Unless 
the electrode has been allowed to cool before removing, no haemor- 
rhage or only slight oozing occurs. There is also less discomfort fol- 
lowing this method than after others. The cotton should not be 
saturated to the dripping point with the solution so as to allow it 
to trickle down into the throat, and if too much is used it occasions 
a copious serous secretion. Advantage of this power of the strong 
solution to cause stimulation of the glands and osmosis can be taken 
in treating ozama and dry catarrh of the nose and throat. The weak 
solutions diminish secretions; the strong ones increase them. 

For self-treatment of the nose and throat patients have found 
much relief by using an inhaler like that shown in Fig. 23, which 
can be carried in the pocket, and contains a liquified mixture of equal 
parts, by weight, of camphor and menthol. It has a more soothing 



INHALERS. 



15 



and correcting effect on the nerves and vessels than menthol alone. 
It does not become irritating, like menthol-crystals, after being used 
for some time. It can be used unnoticed in public places the instant 
any irritation appears, and thus prevent or cut short attacks. Three 
or four slow, deep inhalations should be taken from it in one nostril 
while the other is closed, or until the irritation is relieved. The 
breath should not pass through the inhaler, but out through the 




Fig. 22. — Hot-water Inhaler, 

mouth instead. To treat the throat it should be inhaled through the 
mouth. 

If we want a drying, detergent, and protective spray, the pine- 
needle oil in a 2-per-cent. solution will accomplish the purpose, and 
it is a most agreeable preparation. In those rare cases in which the 
mucous glands are atrophied and in need of a powerful stimulant to 
excite them to action, the 4- or 10-per-cent. cubeb-spray is the most 




Fig. 23. — The Author's Camphor-menthol Inhaler. 

effective, especially when combined with the 10-per-cent. strength of 
camphor-menthol and benzoinol. 

There is a prevalent mistaken opinion that the cubeb-spray is 
drying to the mucous membrane, while the opposite effect is the true 
one. It is a stimulant and disinfectant. It increases the flow of 
mucus, and if used in too strong a preparation it acts as an irritant. 
Cubeb is useful as a tonic in chronic irritability of the pharynx and 
larynx, especially in the hoarseness of public speakers and singers. 



16 SPRAYS AND INHALEXTS. 

Eucalyptol is antiseptic, and destructive to low forms of life. It 
is a stimulating expectorant, and must not be used in very strong 
solutions, or it becomes an irritant. When combined with benzoinol 
in the proportion of 20 grains to the ounce it is not too strong for 
the majority of patients, but, as a rule, it must be avoided in hay- 
fever patients. Some of them cannot remain in the room where it 
is being sprayed without suffering from paroxysms of sneezing. Car- 
bolic acid combined with benzoinol, 2 grains to the ounce, is valuable 
when the antiseptic and anaesthetic effects are required. It is very 
useful in ozaena, especially when followed with aristol. 

Antiseptic aqueous solutions are necessary for properly washing 
out and cleansing the nasal cavities preparatory to the application of 
other medicaments. Dobell's solution is the most universally used. 
It consists of biborate and bicarbonate of sodium, of each, 1 drachm; 
carbolic-acid crystals, 12 grains; glycerin, 2 drachms; water, enough 
to make 8 ounces. Seller's antiseptic solution is also satisfactory, and 
is easily and quickly made by dissolving one of his tablets in 2 ounces 
of pure water. These solutions dissolve, loosen, and wash out the 
secretions and crusts, so that the diseased membrane itself can be 
reached. Manv other formulae will be found in the appendix. 



CHAPTER II. 
DISEASES OF THE NASAL CAVITIES. 

Influenza. 

Theke are two types of this disease. One is an uncomplicated 
catarrhal condition of the respiratory tract prevailing generally dur- 
ing the changes of the seasons from fall to winter and from winter 
to spring, and may appear at any time during the year. The other 
is of an epidemic nature and is known under several names, as fol- 
low: The grip; grippe; epidemic catarrh, or catarrhal fever; blitz 
catarrh; epizootic. Since the treatment of the severer variety will in- 
clude that of the milder, we will consider the subject of the epidemic 
form. 

Epidemics of influenza date back beyond the Christian era, and 
as early as the year 415 B.C. the Athenian army in Sicily was afflicted 
with this trouble. There is a periodical outbreak of a similar disease, 
occurring twice a year, in January and August, in the Caroline Is- 
lands, from which nearly all the inhabitants suffer; but this is very 
suggestive of hay fever. In the year 1510 the British Islands were 
visited by a very extensive epidemic of influenza, but up to that time 
no exact records of it were written. Since that period there have 
been more than twenty outbreaks of severe type, besides many minor 
ones. 

The disease usually is first manifested in the far East, generally 
in some part of Russia, and travels rapidly from east to west. The 
greater the facilities for rapid transit, the faster it invades the western 
countries. It has traveled from near St. Petersburg to New York in 
six weeks. It prevails in all climates and attacks all classes of society, 
but infants enjoy partial immunity. While it has been made the butt 
of jest by the uninformed masses and the subject of ridicule by the 
unthinking triflers in medicine, it is more to be feared than small-pox 
or cholera. It cannot be quarantined and controlled by protective 
measures like those diseases, and when it does not kill it blights and 
withers and leaves its deadly sting to blot out one's sight, or hearing, 
or reason, or sows its morbific seeds in other organs to insure its vic- 

2 (I?) 



18 INFLUENZA. 

tims future maladies. When it first appeared in Paris the effects were 
worse than any of the three epidemics of cholera during the thirty 
years preceding 1884. The influenza epidemic of 1891 in Chicago, 
lasting about six weeks, produced the highest mortality the city had 
ever known. 

Pathology. — The exact nature, cause, and method of origin and 
propagation of this disease are not yet definitely determined. It is 
easier to say what it is not than to say precisely what it is. It is not 
a simple catarrhal affection. It is a specific, infectious, and contagious 
disease. The principal manifestations occur in the mucous membrane 
of the respiratory tract. There are congestion and swelling of this 
membrane in the nose, throat, and larynx, and sometimes extending 
as far as the bronchial tubes. In certain cases the inflammation in- 
vades the gastro-intestinal canal. F. B. Turck illustrates the im- 
portance of clearing the nose and throat of diseased conditions. He 
demonstrated that the micro-organisms found in diseased stomachs 
were the same as those found in the post-nasal cavities and mouths of 
the same patients. 

Various bacteria have been found in the sputa of persons suffer- 
ing from this disease. Staphylococci and streptococci were especially 
abundant, but it is still an open question as to what actually consti- 
tutes the specific infection that gives rise to the attack. Some ob- 
servers believe that the true influenza bacillus has been found, while 
others are of the opposite opinion and suggest that the micro-organ- 
isms found may be the product instead of the cause of the disease. 

Richard Pfeiffer announced in 1893 that he had discovered the 
specific germ of influenza, and his claim has been largely credited. 
Pfeiffer's organism is a short, plump bacillus, found chiefly in the 
purulent secretion from the respiratory tract in influenza. 

It seems reasonable to assume, from the rapidity with which the 
whole organism shows the presence of infection, that it first enters 
the blood. Xo other theory yet advanced satisfactorily accounts for 
all the phenomena that it presents. 

Etiology. — Epidemic influenza is believed by some to be caused 
by peculiar atmospheric conditions, which would account for its rapid 
extension over a large part of the globe and appearing in widely 
separated places al nearly the same time. We know that the upper 
strata of the atmosphere, in which volcanic dust is disseminated, will 
carry these particles t<> the remotest regions of the earth, and that 
dense poisonous gases evolved from subterranean sources may be ex- 



INFLUENZA. 19 

traded into the great ocean of atmosphere about rib and prove detri- 
mental to animal life. 

During some invasions meteorological records have shown high 
barometric pressure, drought, northerly winds, cloudy sky, diminution 
of ozone, and low electrical charge of the air. While the prevailing 
winds have varied greatly in different countries during the same epi- 
demic, extremely dry air has been a constant factor. This unusual 
dryness of the air and earth has led some to believe that the conse- 
quent liberating and floating of the resulting dust in the air and its 
inhalation and irritating effects upon the respiratory passages ac- 
counted for attacks. But a severe epidemic arose in Eussia while the 
country was covered deeply with a carpet of snow; and, moreover, the 
respiratory system is not invariably involved. 

It is claimed by some observers that the epidemic does not travel 
faster than man; that obstacles to travel, like mountain-ranges, ob- 
struct its progress; that the most popular means of communication 
between people of different countries form the routes by which the 
disease progresses; and that it first gains foothold in large cities, where 
persons congregate in the greatest numbers: post-offices, factories, 
schools, banks, etc. All these facts point to the harboring and convey- 
ing of the germs of influenza by human beings. 

Symptomatology. — The variations of the disease as it appears in 
different individuals, and even in the same person, are susceptible of 
classification under three natural divisions of the subject: as it affects 
(1) the nervous system, (2) the alimentary canal, and (3) the respira- 
tory tract, including the Eustachian tube, middle ear, and pneumatic 
cells of the mastoid- process. We are especially concerned with the 
latter form. 

It is not common to see all of these forms affect the same patient 
at the same time, but it is not uncommon to see two of them co-exist. 
For example: The great mental depression with extreme prostration 
of the muscular system that first makes its appearance may be quickly 
followed by the gastric and intestinal disturbances that add to the 
exhausted condition already present. We often see the nervous and 
respiratory forms combined, but not the simultaneous invasion of the 
air-passages and alimentary canal. 

Two of the three forms are sometimes consecutive to each other. 
To illustrate: One of our younger professors in the Post-graduate 
Medical School was attacked during the epidemic with vomiting and 
purging and general prostration, from which he nearly recovered in 



20 INFLUENZA. 

five days, when he was seized with sneezing, running at the nose, sore 
throat, hoarseness, and mild bronchitis. 

Chilliness and heat may often be marked when the temperature 
rises only one or two degrees, but the rise is often to 103° or 104° 
F. In addition to a sudden sense of great fatigue there often occur 
shooting pains in the head, pain and muscular soreness in the ex- 
tremities or abdomen, aching of the back and loins, and in the 
respiratory form coryza, pharyngitis, and often an invasion of the 
lower air-tract. 

We have observed that patients with an unusual form of middle- 
ear disease begin to present themselves in both private and dispensary 
practice about one week after we become conscious of the presence 
of an epidemic of influenza. They often present this story: "Doctor, 
I was taken a few days ago with a cold in the. head, and I had a great 
pain in my ear last night. It broke during the night and ran blood 
and water." They present a picture of acute suffering, anxiety of 
countenance, weakness of the limbs; coated, indented, and tremulous 
tongue; and complain of pain radiating over the corresponding side 
of the head. The mastoid is more often involved than in the simple 
middle-ear inflammation complicating influenza between epidemics. 
The external-ear canal is found to contain bloody serum; the drum- 
head is red, swollen, and bulging; and the tympanum is filled with 
discharge. The hearing is usually much impaired. 

Diagnosis. — As soon as the catarrhal symptoms of the respiratory 
tract make their appearance, the diagnosis is a simple matter. The 
symptoms already enumerated are sufficient to decide the question, 
and the presence of an epidemic will suggest the nature of the com- 
plaint. 

Prognosis. — Eobust individuals are able to resist the attacks suffi- 
ciently to recover in a few days or weeks, but persons already debili- 
tated or suffering from diseases of vital organs are prone to succumb 
cither during the attacks or as a sequel to them. 

While the general statement may be made that a small percent- 
age of cases die during the attacks, this does not convey any ade- 
quate idea of the actual damage done by an epidemic, because, in the 
first place, -nth vast numbers of the population fall victims to its 
ravages, and, in the second place, many die, or are made defective, 
as its sequel. 

Treatment.— The patienl is put to bed and the bowels relaxed if 
aecessary. When the temperature is high it is reduced with anti- 



ACUTE RHINITIS. 21 

pyrin or one of its efficient substitutes, and the pain and other dis- 
tressing symptoms are relieved by the coryza tablets containing a com- 
bination of morphia, atropia, and caffeine in the proportion of 1 / 12 
grain of morphia with 1 / 600 grain of atropia and 1 / 6 grain of caffeine. 
The morphia relieves the pain and nervous irritability, suppresses the 
excessive secretions, and stimulates the circulation; the atropia ele- 
vates the tone of the blood-vessels, quickens the pulse, decreases all 
the secretions except the urine, stimulates the respiratory centre, and 
counteracts the constipating effect of the morphia; and the caffeine 
stimulates the nervous centres and the kidneys and diminishes the 
tendency of the morphia to produce nausea. The sneezing and nasal 
discharge cease, the nostrils open up, and the pain disappears. 

We treat the nose and throat with a 3-per-cent. solution of cam- 
phor-menthol in lavolin or benzoinol with the atomizer three or four 
times a day. 

This treatment, with repetition of the doses as the symptoms 
demand, minimizes the suffering, diminishes the intensity of the dis- 
ease, and shortens its course. For rheumatic symptoms salicin or 
salicylate of sodium should be given. Complicating diseases .call for 
their appropriate treatment on general principles. 

Acute Ehinitis. 

Synonyms. — Cold in the head; coryza; acute nasal catarrh. 

Pathology. — Simple acute rhinitis is an acute inflammation of 
the mucous membrane of the nasal cavities. The first stage is char- 
acterized by an engorgement of the blood-vessels, not only of the 
mucous membrane, but of the turbinated bodies also. The membrane 
is abnormally red, dry, and swelled. The turgescence of the vessels 
remains during the second stage of the inflammation; but the mem- 
brane becomes bathed in mucus and a copious exudation of serum, 
the strong saline character of which irritates the nostrils and the 
cutaneous surfaces bordering them. Numerous white blood-corpus- 
cles escape from the vessels into the surrounding tissues; and in- 
creased cell-proliferation in the mucosa announces the third stage. 
Now the character of the secretions changes from a mixture of serum 
and mucus to a muco-purulent and finally a purulent discharge. It 
is more common to childhood than adult life, and the aged are rarely 
afflicted with it. Coryza forms one of the symptoms of the eruptive 
fevers, and sometimes occasions more distress than the disease it 
accompanies. 



22 ACUTE RHINITIS. 

Etiology. — Taking cold is the commonest cause. The impression 
of cold on certain surfaces of the body appears to paralyze the inhibi- 
tory power of the vasomotor nerves controlling the capillary circula- 
tion of the nasal mucous membrane. The most vulnerable surfaces 
are the back of the neck and head and the feet. In speaking of the 
causes of two of the principal symptoms of rhinitis and the manner 
of their production, Joseph- A. White says: "Such phenomena differ 
somewhat in different persons, as I have found by experiments made 
upon myself and others. If I irritate my intranasal tissues it takes 
some time to produce any reflex whatever, but the first to be mani- 
fested is lacrymation on the side irritated, followed by evident swell- 
ing of the corpora cavernosa and by a serous exudation; cough I can- 
not produce at all. On the contrary, if I sit in a warm room with 
my back to an open door or window, I will begin to sneeze almost 
before I am aware of the draught of cooler air. I have observed the 
same effect in others, while, in some, artificial irritation of the nose 
will cause sneezing immediately, and in nearly all such persons 
continuance of the irritation will cause cough." The climatic and 
meteorological causes are discussed in Chapter XXVIIL The nervous 
temperament predisposes to this affection. Wagner considers that 
rhinitic affections are in many cases due to the immigration of micro- 
organisms from the tonsils when they are diseased. The uric-acid 
diathesis predisposes one to this disease. 

Symptomatology. — The earliest manifestation of cold in the head 
is a sensation of dryness or irritation in the nose, prompting one 
to snuff the air as if to dislodge some foreign substance. This gives 
place to itching, tickling, or stinging sensations, followed by parox- 
ysms of sneezing, copious flow of serum and mucus from the nostrils, 
suffusion of the eyes, lacrymation, flushed countenance, and possibly 
sensations of constriction and pain over the eyes in the frontal sinuses, 
and headache. 

The discharge, if continued long, becomes acrid and irritating 
to the nasal opening and upper lip, producing redness, excoriations. 
and clacking of the skin over which it spreads. The efforts of the 
patienl to keep the nose and lip dry result in the removal of the 
epidermis t" such an extent as to leave a raw-appearing surface. One 
of tli.' mosl distressing symptoms is the nasal stenosis produced by 
the greal swelling of the aasa] membrane and turbinate bodies. This 
interferes with swallowing as well a- breathing. Respiration takes 
place entirely through the mouth, and the attempt.to swallow liquids 



ACUTE RHINITIS. 23 

results in their being forced upward into the nasal space or even into 
the Eustachian tubes. The sense of smell is diminished or absent and 
the voice indicates the seat of the trouble. It has a characteristic 
nasal quality, and the sounds of m and n cannot be produced. The 
disease may extend to the antrum of Highmore, the frontal sinuses, 
the ethmoid or sphenoid cells, or the Eustachian tubes and middle 
ears. 

Diagnosis. — The group of symptoms described presents so char- 
acteristic a picture that there is no likelihood of confounding this dis- 
ease with any other, but it must not be forgotten that it is a symptom 
of the exanthemata. 

Prognosis. — If the inflammation does not extend to the accessory 
cavities, recovery can be expected in a few days, but may be post- 
poned longer in severe attacks. 

Treatment. — The course pursued in the treatment of influenza, 
varying according to the severity of the attack, can be relied upon 
here. Indeed, this disease can be averted by the use of the coryza 
tablets mentioned for influenza, containing caffeine, morphia, and 
atropia. By giving one of these at the onset of the attack the symp- 
toms subside with as much certainty as can be affirmed of any me- 
dicinal specific. The effect of this remedy lasts several hours, although 
the dose is small, and it should be repeated in two, four, or six hours 
if the symptoms begin to reappear. (See page. 21.) 

Prescriptions for the coryza tablets should never be given to 
patients. I have never allowed them to know the composition of the 
tablet, and. for this reason no patient has ever contracted a drug habit 
through my carelessness. It would be much better to give the little 
tablets gratuitously than to run any risk whatever of becoming re- 
sponsible for a baneful habit. 

In the uric-acid diathesis (see Chapter III) lithia should be given, 
and the diet should be carefully regulated (page 50). The writer 
has often aborted attacks by the effervescent lithia preparations given 
in 6- to 10-grain doses two or three times in the twenty-four hours 
for one or more days. 

"There is a condition in which the inferior turbinated bodies are 
red and turgescent, which will not collapse under local applications of 
cocaine, but which will yield very kindly to colchicum. Gouty intox- 
ications or irritations have been observed in the nose, pharynx, and 
larynx, especially by English specialists." (W. L. Ballinger.) 

Spraying the nose with a 3-per-cent. solution of camphor-men- 



24 SIMPLE CHRONIC RHINITIS. 

thol in lavolin or benzoinol (Figs 11 and 12) affords great relief. 
The physiological effects and uses of this remedy are dwelt npon in 
Chapter I. 

The camphor-menthol pocket-inhaler (Fig. 23) affords much relief 
in mild attacks. Its uses are given in the preceding chapter. It 
affords not only a very refreshing inhalent, but, if employed as soon as 
the first nasal irritation is felt, the symptoms may be checked. 

An important preventive measure is the protection of the body 
from the vicissitudes of the weather. Fabrics of vegetable fibre, such 
as cotton and linen, should not be worn next to the skin. Animal 
fibre, such as woolen or silk, favors absorption and evaporation of the 
perspiration, keeps the temperature of the surface of the body equable, 
and prevents chilling. Woolen is preferable to silk, except in the 
hottest weather, when silk underwear affords more comfort and suffi- 
cient protection. 

Simple Chronic Ehinitis. 

Synonyms. — Chronic coryza; blennorrhoea; rhinorrhoea; puru- 
lent catarrh. 

Pathology. — This is a chronic inflammation of the nasal mucous 
membrane, generally consequent upon recurring seizures of acute 
coryza.. The membrane is swollen and puffy and the venous sinuses 
are dilated and relaxed (vasoparesis). Extensive infiltration of the 
interstitial tissue with serum and leucocytes occurs, with a consequent 
hydrorrhcea and degeneration into pus-cells. The mucous glands are 
excited to increased activity, necessitating a frequent resort to the 
handkerchief to prevent dripping from the end of the nose. The mem- 
brane is easily irritated by dust, gases, and sudden changes in the 
weather. 

Etiology. — Exposure to damp and cold and an atmosphere loaded 
with irritating gases or dust act as direct exciting causes. A nervous 
temperament and the strumous diathesis predispose to the disease. 
Uricacida?mia is sometimes an important predisposing cause. 

Symptomatology. — The increased nasal discharge is the most 
prominent feature, and the end of the nose may become so irritated 
as to give it a red and swollen appearance. The secretions consist of 
mucus and serum, or pus formation takes place to such an extent as 
to fill the nares with a yellow discharge. Its presence provokes fre- 
quent hawking and expectoration. Sneezing is not a constant or fre- 
quent symptom ;is compared with acute coryza or hay fever. An 



PLATE II. 



PLATE II. 



Figure 1. — Male, set. 38; hypertrophy of the entire mucous membrane of the 
nasal cavities; relieved by means of bougies and galvanocautery. 

Figure 3. — Rhinoscopic view of above (normal size). 

Figure 2. — Male, set. 30; syphilitic perforation and exostosis of septum; mer- 
curial treatment and mitigated stick locally. 

Figure 4. — Rhinoscopic view showing exostosis of septum in the above (normal 
size). 

Figure 5. — Female, set. 26; appearance of nasal cavity after loss of septum and 
turbinated bones, and enlargement of the orifice of the antrum through syphilitic 
necrosis. Mercurials and iodides; extraction of necrosed bones with forceps. Potas- 
sium-permanganate washes. 

Figure 7. — Rhinoscopic view of above with mirror facing obliquely from left 
to right (normal size). 

Figure 6. — Female, set. 17; syphilitic perforation of hard and soft palate; mer- 
curials and iodides; mitigated stick locally. 

Figure 8. — View of palate through the mouth (in state of active inflammation). 

Figure 9. — Female, set. 19; mucous polypi; removed with snare; subsequent 
galvanic cauterizations. 

Figure 11. — Anterior view of above (normal size). 

Figure 10. — Female, set. 45; large mucous polypi; removed with snare; sub- 
sequent galvanic cauterizations. 

Figure 12. — Anterior view of above (normal size). 

Figure 13. — Female, set. 30; large fibrous polypus of pharyngeal vault; re- 
moved with electric snare. 

Figure 14. — Male, set. 28; central curvature and exostosis of septum; longi- 
tudinal incision with knife; oakum plugs; exostosis removed with saw 



[Note. — Represented as seen by gaslight. By daylight the red color appears much 

paler.] 



PLATE II. 





SIMPLE CHRONIC RHINITIS. 25 

annoying sensation of fullness in the head — especially if the infundib- 
ulum, or passageway from the frontal sinus to the nose, is obstructed 
■ — may lead one to suspect involvement of the sinus. 

There is a tendency for this disease to extend to the Eustachian 
tubes, the middle ears, or the nasal ducts, causing impairment of 
hearing or obstruction of the natural tear-passages. The thickening 
of the membrane and the turgescence of the turbinate bodies so con- 
strict the meatuses as to impart a nasal intonation to the speech. 
The walls of the passages are frequently seen to be agglutinated 
together by a viscid, tenacious secretion, or bathed in pus. The 
membrane is generally redder than the normal, but in the variety in 
which the hydrorrhea is abundant it may appear of a pale-pink tint 
or even livid. 

The secretions may become dry and inspissated to the degree of 
crust formation. These adhering crusts excite a desire to pick at the 
nose until they are removed. This constant source of irritation and 
depriving the septum of its natural protection in the process of repair 
result in perforation in that part of the cartilaginous septum near the 
border of the nares. 

Diagnosis. — To distinguish between this and hypertrophic nasal 
catarrh it is essential to use the probe and cocaine. When the probe 
is pressed upon the turbinals in simple chronic rhinitis it sinks into 
a body comparable to a wet sponge, for the tissues are distended with 
the infiltrated fluids. The depression caused by pressure fills slowly 
like that of a dropsical body. In the hypertrophic variety the probe 
meets with a firm, resisting, fibrous tissue, which possesses greater 
resilience. Cocaine contracts the tissues, in the simple form, until 
they hug the bone, leaving a wide air-space; but not so in the hyper- 
trophic variety. In the latter the surface is uneven, in the former 
smooth. Suprarenal solution, may be used instead of cocaine. 

Prognosis. — Patients are skeptical as to the curability of nasal 
catarrh. It is so common an affection, especially in the region of the 
Great Lakes, that the inhabitants think that, as a matter of course, 
they must expect to suffer from it. However, with an advantageous 
combination of treatment and hygienic measures, a euro can confi- 
dently be predicted. But one is not warranted in promising no re- 
turn of the trouble under provocative conditions. 

Treatment. — The first requisite to success is cleanliness of the 
nasal cavities. This is best obtained by the use of sprays, — such as 
DobelFs, Seller's, and other solutions, — mentioned in Chapter I. 



26 SIMPLE CHRONIC RHINITIS. 

These can be injected successfully with the hand-atomizer (Figs. 11 
and 12) if one lack a large air-compressor. Eight pounds' pressure 
is sufficient to thoroughly wash the cavities without any likelihood 
of invading the Eustachian tubes. 

After the membrane is thoroughly cleansed oleaginous sprays 
are indicated to protect the surface, stimulate the absorbents, con- 
tract the blood-vessels, disinfect, and render the mucosa less sensi- 
tive. These remedies are treated of in Chapter I. An effective treat- 
ment consists in throwing a fine nebula of a 10-per-cent. solution of 
camphor-menthol in lavolin, by means of the vaporizer (Fig. 13), fol- 
lowed by a spray of the following infusion made with lavolm: 
Calendula, 1 per cent.; hamamelis, 2; pinus strobus, 2; lavolin, 95. 
Camphor-menthol in the nebula does not bathe the membrane with 
the liquid, but relieves the irritability and stenosis and prepares the 
parts for the coarser spray which will remain in contact with the dis- 
eased surface for many hours. 




Fig. 24.— The Author's Soft-rubber Nasal Bougie. 

Another excellent spray consists of: Camphor-menthol, 3 parts: 
pine-needle oil, 2; eucalyptol, 1; and benzoinol, 9-1 parts. (See 
Appendix.) 

This treatment is best given two or three times a week by the 
surgeon, while the patient pursues a home treatment with a suitable 
atomizer and medicament in order to prolong the effect of each office 
treatment and render it continuous. Cocaine is not mentioned by the 
author as a therapeutic agent, because it is not of such a nature as to 
effect permanent results, and because of the imminent danger of con- 
verting one's patron into a pernicious-drug slave. Cocaine has no 
place in my practice except as an anesthetic in surgical procedures. 

Bougies and dilators of medicated gelatin, hard and soft rubber 
(Fig. 21), and metal are useful in reducing the engorgement of the 
turbinate bodies and overcoming contact and pressure of these bodies 
upon the septum. The bougies adapted in contour and size to each 
individual msc are introduced between the tnrbinals and septum for 
a tew minutes at first, beginning with the smaller, and used on the 
same principle as sounds and dilators in other departments of surgery. 



CEREBROSPINAL RHINORRHCEA. 27 

When the engorgement of the vessels of the turbinate bodies 
produces great intumescence of those structures and consequent 
constriction of the nasal passages that proves unyielding to the meth- 
ods already mentioned, the cautery is indicated. The electro- 
cautery is the most effective, but in its absence chemical cauteries 
can be substituted. A detailed description of the apparatus and 
methods will be found in the treatment of hypertrophic rhinitis. 
The question of proper clothing is considered in the treatment of 
acute rhinitis. 

Suprarenal extract has proven beneficial in cases of nasal hydror- 
rhoea. B. Berens has reported the cure of a patient with hydrorrhcea 
by the use of suprarenal extract in 5-grain doses every three hours. 
C. P. Linhart reports, as being equally effective, a spray of DobelFs 
solution with a drachm of suprarenal extract to the ounce. His patient 
had a recurrence of the discharge in the winter, but it yielded promptly 
to the same local treatment. ("American Year-book," 1902.) 

Cerebrospinal Ehinorrhcea. 

The escape of cerebro-spinal fluid by way of one or both nostrils 
is of infrequent occurrence. The amount of fluid exuded varies from a 
slight quantity to a pint or more in twenty-four hours, and handker- 
chiefs wet with it dry stiffened. The discharge may be intermittent 
or almost continuous. The differentiation between this affection and 
common nasal hydrorrhcea, and discharges originating in the cavities 
accessory to the nose, is attended with some difficulty. The excessive 
serous and sero-mucous flux in hay fever is suggestive of the escape 
of cerebro-spinal fluid. 

St. Clair Thompson presented an elaborate paper on this subject 
before the British Medical Association in 1898. He believed that 
in the majority of cases reported the condition was not a distinct 
morbid entity, but a symptom of various affections, and that it is 
necessary to avoid anything that might lead to infection. He recom- 
mended such treatment, only, as is useful in hay fever, employed the 
electrocautery with moderation, if at all, and depended largely on 
climatic and general tonic remedies. 

L. Hektoen has reported a case in which C. Fenger removed what 
appeared to be a polyp from the nose, but it proved to be a portion of 
a meningocele. An opening was made through the face, and the edges 
of the dura were sutured. A prompt and permanent cure resulted. 



28 CEREBRO-SPINAL RHIXORRHCEA. 

"Hektoen thinks the route of escape of the fluid is along the perineural 
sheaths of the olfactory nerves. Treatment promises little, but early 
recognition of the condition may prevent infection of the meninges 
through the nose." ("Year-book of the Nose, Throat, and Ear/' 
1901.) 

In some instances it has been observed that when the flow ceased 
for a time symptoms of cerebral pressure developed. These were re- 
lieved soon after an abundant discharge of clear fluid from the nose 
occurred, the composition of which was identical with that of the 
cerebro-spinal fluid. 



CHAPTER III. 
DISEASES OF THE XASAL CAVITIES (Continued). 

Hay Fevee. 

Synonyms. — Nervous catarrh; nervous cor} T za; hay asthma; rose 
cold; June cold; July cold; peach cold; summer catarrh; autumnal 
catarrh; pollen poisoning. The Latin equivalents are catarrhus 
asstivus; coryza vasomotoria periodica. French equivalents: catarrhe 
d'ete; catarrhe de foin. German equivalents: Fruhsommer-catarrh; 
Heu-asthma. Italian equivalent: asma dei mietitori. 

Pathology. — In a paper read before the Section on Psychological 
Medicine and Nervous Diseases of the Ninth International Medical 
Congress in Washington in 1887, the author argued the neurotic char- 
acter of this disease. The assembly, which was very large and repre- 
sentative, agreed almost unanimously to the theory that hay fever is 
a neurosis. Only three members who participated in the discussion 
dissented from this view. 

The name "hay fever" is a misnomer. It is employed to desig- 
nate a condition to which numerous other terms have been applied 
with equal fitness. To the array of names already in use, ill-chosen 
'because they are misleading, the author had the temerity to add 
another. In a published lecture, delivered in the Chicago Medical 
College in 1885, he proposed the term "nervous catarrh." Since then 
several authors have adopted this expression. One writer, however, 
calls it nervous coryza; but coryza is from the Creek xopv^a, sig- 
nifying only a running at the nose, while the word catarrh, from 
xaTapoECd, admits of a much broader application and, with properly 
modifying adjectives, may be used to designate affections of various 
mucous membranes. Coryza is a specific term; catarrh is generic, 
and obviously is the more correct one to characterize a disease which 
is not necessarily confined to the nasal cavities. Nervous catarrh is 
so comprehensive a term, and is so tersely suggestive of the pathology 
and symptomatology of certain neurotic derangements, as to be sus- 
ceptible of a much larger usefulness than has been accorded it. To 
illustrate: There is a truly nervous intestinal catarrh which attacks 

(29) 



30 HAY FEVER. 

and leaves a certain class of individuals of the nervous temperament 
as suddenly as an attack of hay fever does. The writer has known a 
musician to suffer from severe attacks of diarrhoea just previously to 
his appearance before an audience which he was announced to en- 
tertain. Immediately after his performance all symptoms of intestinal 
disturbance would vanish, only to return again at his next appearance 
in public. We might cite a case of an orator of the evening who was 
similarly afflicted. The nervousness induced by the contemplation of 
addressing his audience would so react on the nervous supply of the 
intestinal tract as to cause sudden and copious diarrhoea. No sooner 
would his oration be finished than all unpleasant symptoms ceased. 
I have known surgeons to be similarly affected. We have nervous 
dyspepsia occasioned by mental emotions. A certain combination of 
objective and subjective causes operating on one individual produces 
morbid phenomena referable to the mucous membrane of the turbi- 
nated bodies, resulting in an attack of hay fever, — nasal nervous ca- 
tarrh. In another, the seat of the resulting manifestations will be in 
the bronchial mucous membrane, eventuating in an attack of asthma, 
— bronchial nervous catarrh. In yet another the intestinal mucous 
coats are the scene of this breaking of a nerve-storm, resulting in 
copious watery discharges, — intestinal nervous catarrh. All these 
are undoubtedly co-ordinate morbid conditions of the nervous sys- 
tem, finding expression in exaggerated and perverted functional ac- 
tivity. 

The pathology of this disease has been evolved from a chaotic 
state, in which it remained from the time of its first description by 
John Bostock, of London, in 1819, until recent years. Instead of 
looking upon hay fever as a simple congestion or inflammation of the 
Schneiderian membrane, as eminent English authorities have in the 
past, prominent American authors favor the neurotic theory. In this 
connection it is interesting to note that a writer for the London Lancet 
treats of common nasal catarrh as a reflex neurosis, and, in support 
nf his position, adduces numerous instances in which purely nerve- 
remedies succeeded in arresting attacks of acute coryza. 

Although this malady is essentially due to an abnormal suscepti- 
bility of nervous tissue, there exists no organic lesion of the nervous 
<( ntres to which the disease is attributable. Being a functional dis- 
turbance, it never <lestroys life, and no opportunity is afforded the 
neuropathologist to make post-mortem observations. But, if the affec- 
tion be a reflex neurosis, can we hope for microscopy to determine 



HAY FEVER. 31 

with precision the condition of nervous structure which primarily con- 
stitutes the disease? 

The arrangement of the nervous supply of the respiratory pas- 
sages is favorable to the existence of reflex nervous phenomena. One 
sympathetic nervous centre, the sphenopalatine ganglion, supplies 
branches to the lining membrane of the nose, pharynx, and Eusta- 
chian tubes. It has a motor, a sensory, and a sympathetic root. It 
communicates with the facial and pneumogastric nerves, thus uniting 
in the closest connection the nose, pharynx, middle ear, larynx, and 
bronchi. Furthermore, the Schneiderian membrane is continuous 
with the lining membrane of the nasal duct and eyelids, the pharynx, 
Eustachian tubes and tympana, the larynx, trachea, and bronchial 
tubes. Ablation of the sphenopalatine ganglion sets up a severe ca- 
tarrhal state of the Schneiderian membrane. A congestion once 
started in this structure may extend with unobstructed facility to the 
contiguous membranes, very like the spreading of an erysipelatous 
inflammation from one area of the skin to another. But the continu- 
ousness of the membranes throughout these various organs does not 
satisfactorily account for all the symptoms produced in one part by 
impressions upon another. Certainly an inflammation in the throat 
may extend along the Eustachian tube to the tympanum, but there 
is no such reason to account for the sudden transitory tinnitus aurium 
which occurs in some persons immediately upon the ingestion of a 
draught of cold water or the inhalation of tobacco-smoke, or for the 
cough which is occasioned by the contact of instruments with the 
external auditory meatus or with the inferior turbinated body or the 
septum nasi, or for the paroxysm of sneezing produced by irritating 
the scalp. All these S3 r mptoms are examples of reflex nervous im- 
pulses, and these intimate sympathetic relations between various por- 
tions of the animal economy exhibit themselves with exceptional force 
in patients of a nervous temperament. 

The theory that lesions situated in the nasal cavities may be 
responsible for the existence of common asthma is generally accepted, 
and this is directly in the line of our reasoning, for it argues the reflex 
neurotic character of a disease which possesses close kinship to hay 
fever not only in its etiology, symptomatology, and therapeutics, but 
in the morphology of its secretions. The manner in which exciting 
•causes bring about attacks in hay fever is much the same as in the 
<3ase of asthma. In a hay-fever subject, let brilliant rays of light fall 
upon the retina, or dust impinge upon a sensitive area of mucous 



32 HAY FEVER. 

membrane, and what occurs? The end-organs of the sensory nerves 
supplying the part affected, being oversensitive to the presence of that 
particular kind of stimulus, are instantly thrown into a state of in- 
tense, excitation or irritation. Immediately the impression is flashed 
along the sensory nerves to a nervous centre, — brain or ganglion; 
thence, changed to motor impulse, it is switched back, on the one 
hand, along the vasomotor nerves to the blood-vessels of the seat of 
irritation, causing dilatation, engorgement, swelling, and flux; and, 
on the other hand, along the pneumogastric and sympathetic nerves 
to the muscles concerned in the act of sneezing, and, through ex- 
tensive sympathetic nervous relations, all the respiratory tract and its 
connections may participate in the disturbance and become involved 
in a fully developed attack of hay asthma, — sneezing, coughing, 
wheezing, nasal flux, expectoration, and lacrymation. 

It appears, from the manner in which the paroxysms of hay 
fever are started and developed, that there are three conditions upon 
which the existence of the disease depends: (1) abnormally susceptible 
nerve-centres, (2) hyperesthesia of the peripheral termini of the sen- 
sory nerves, and (3) the presence of one of a large variety of irritating 
agents. Exclude one of these conditions and the paroxysms are pre- 
vented. Allay the susceptibility of the nervous centres by certain 
cerebral sedatives, and an attack is averted or arrested. Anesthetize 
the nervous supply of the oversensitive areas and the result is the 
same. Eemove the patient beyond the reach of exciting causes and 
he is as comfortable as any mortal. 

Another fact in support of the theory that this is a functional 
disease of the nervous system is its hereditary character. We might 
quote many illustrative cases, but three representative ones will suf- 
fice: In Dr. Morrill Wyman's family there were six sufferers from hay 
fever besides himself. In the family of the Eev. Henry Ward Beecher 
there were two besides himself; and in the family of Chief-Justice 
Shaw there were six members who had different forms of this dis- 
tressing malady. To be sure, heredity alone does not establish a 
neurotic character; but, taken in connection with all the other facts 
in the case, it is a weighty argument in support of the assertion that 
this is a constitutional disorder of a neurotic type. 

Again, the nervous temperament is the predominating one in 
this class of patients, — an argument which needs no elucidation, — 
and the same may be remarked concerning asthmatic sufferers. The 
periodicity of the disease points to nothing if not to its nervous- 



HAY FEVER. 33 

nature, for one cannot conceive how the pollen theorists from their 
point of view can reconcile this feature of the complaint with their 
own doctrine. Is it reasonable to assume that the pollen of various 
plants that give rise to attacks in different individuals will be set 
free to float away on their fructifying pilgrimages on exactly the same 
day, and at nearly the same hour, each recurring year, and that they 
will reach the nostrils of sufferers in their varying localities and situa- 
tions and vocations simultaneously year after year? The variations 
that occur in the yearly advance of the seasons preclude this hy- 
pothesis. And, again, the identity of the different forms of the mal- 
ady strengthens the nerve theory, while it weakens the pollen argu- 
ment, for it shows that the disease exists under conditions that are 
the least favorable to the operation of pollen; in fact, where the 
pollen theory is inadmissible, — in the winter and spring. The author 
does not undervalue the importance of pollen as an exciting cause, 
but he wishes to be understood as maintaining that it constitutes only 
one of three factors which render the existence of the disease possible. 

Other arguments that may be briefly mentioned are the sudden- 
ness of the onset and disappearance of attacks, the fact that the most 
potent palliatives are nerve-sedatives, tonics, and stimulants, and that 
mental emotion and physical exertion may prevent or arrest parox- 
ysms. 

The chief argument urged against the nerve theory is that many 
hay-fever patients have diseased nasal cavities. But we may say the 
same of that much larger proportion of our population who have no 
experience with hay fever. That we should find nasal hypertrophies, 
etc., concurrent with hay fever is not surprising in this catarrh- 
producing climate. Indeed, the diseased turbinated tissue may be a 
coincidence or sequence rather than the cause, for it is natural to 
suppose that years of constantly recurring attacks of even functional 
disturbance of the vasomotor supply of these parts would result in 
a passive hyperemia which would eventuate in proliferation of cells in 
mucous and submucous tissues, and the growth of hypertrophies 
which might serve as a nest for the reception and retention of irri- 
tating agents. But the argument that this condition is responsible for 
hay fever in infants, youths, and even in adults in whom there is no 
evidence of inflammatory changes before or between attacks is not ten- 
able. The paroxysms do not so much resemble symptoms of an inflam- 
mation as they do an irregular and explosive discharge of a superfluity 
of nervous force, — a nerve-storm, if the expression may be permitted. 



34 HAY FEVER. 

• It has been hoped that destructive treatment of the sensitive areas 
in the nasal cavities would permanently cure hay fever, and many 
cases have been so treated by American physicians during the last 
twenty years. However, the most sanguine practitioners of this method 
have confessed considerable disappointment at the results. Some 
cases that were supposed to have been cured still suffer, while others 
are benefited. So far as we have been able to obtain definite data, 
they demonstrate that not much more than one-half the number cau- 
terized are claimed to be cured. This points to the fact that it is 
not a simple local inflammatory disease. If it were, the treatment 
should be attended with greater success. For the reasons set forth 
one cannot expect this method to cure all; but, granting that it may 
cure many, the nerve theory would not suffer in the least by the 
admission, for it assumes a pathological condition of the receptive 
end-organs of the nerves as well as of the perceptive nerve-ceutres. 
Eliminate the susceptibility of either the central or peripheral nervous 
system, and you remove an essential element in the disease, — destroy 
its entity. But what shall we say of that other large proportion of pa- 
tients in whom paroxysms are produced by irritation of the retina, 
the scalp, etc., or by chilling the skin? Are we to be logical and, 
reasoning from analogy, must we destroy the sensitive areas, enucleate 
our patients' eyes, or scalp or skin them? Yet, if you follow the 
reasoning of this school of theorists to its logical conclusion, it will 
lead to this reductio ad absurdum. 

The neurotic theory is supported by the nature of the following 
causes: Electric light and gaslight; overexertion; anxiety; indiges- 
tion; dampness; chills; gases; feather^; perfumes; odors from ani- 
mals; dry, hot, and impure air; various kinds of fruit, etc. It will 
be observed that pollen and dust do not necessarily enter into the 
causative nature of these excitants. 

This theory receives support also from the fact of the excessive 
irritability and nervousness which patients experience just preceding 
and during attacks. The co-ordinate action of muscles is affected, 
and they complain of feeling jerky and ill-tempered for the time. 

In studying this disease it should not be forgotten that the state- 
ments of sufferers relative to the history and phenomena of their 
maladies should be given greater credence than is usually accorded 
the assertions of other classes of patients, inasmuch as they enjoy the 
distinction of being superior to the average in intelligence and cul- 
ture. This is far from being an idle assertion, for it voices the experi- 



HAY FEVER. 35 

ence of the best authorities and is borne out by reference to the list 
of membership of the United States Hay Fever Association. 

We cannot consider the treatment of this subject as approaching 
completeness without referring briefly to two other important points. 
Microscopists have examined the nasal and bronchial secretions from 
hay-fever and asthmatic sufferers, with the result, it is claimed, of 
establishing the kinship of the two diseases by demonstrating the 
presence in both of products called "gravel." It is believed that this 
so-called gravel accumulates in the secretions of the respiratory pas- 
sages, and acts as a local irritant in the same manner that any foreign 
body would. Analysis may demonstrate that this gravel consists of 
deposits of urate of sodium. 

The force and analogy apparent in the following facts relating 
to neuroses of the skin serve to emphasize the truth in the nerve 
theory: Intense itching over the surface of the whole body may be 
produced by morbid alterations in the ovaries or uterus, anomalies of 
menstruation, diseases of the kidneys, liver, etc. Neumann says: 
"There is no doubt that a large proportion of cutaneous diseases de- 
pend upon disorders of the vasomotor nerves which cause certain 
derangements of circulation in the arteries, veins, and cutaneous 
glands. Anaemia and hyperemia of the skin happen from vasomotor 
irregularities, — some from the brain, some from the spinal cord, — - 
or from the action of cold, or the electric current, etc." 

Now, since it is admitted that there are both immediate and re- 
flex functional nervous disorders of the skin, with what show of 
reason can it be denied that there are similar neurotic disturbances of 
that other skin which covers the interior surfaces of the body? The 
latter membrane is more vascular, more delicate, more sensitive, and 
more highly organized than the skin. It possesses susceptibility to 
all agents which affect the skin, and to many others besides. For ex- 
ample, noxious gases, to which the skin is insensible, will irritate the 
mucous lining of the respiratory organs. The same laws that govern 
the action of the vasomotor nerves of the skin also regulate the vaso- 
motor supply of the mucous membranes. If itching and burning of 
the skin are produced by morbid alterations in the ovaries, so is pru- 
ritis urethrse produced by disease of the bladder; pruritus nasi is 
generally accepted as a sign of worms in children; urticaria results 
from irritation of the gastric or intestinal mucous membrane; so may 
asthma arise in the same manner or from an irritant applied to the 
nasal mucous surface; ear-cough is occasioned by contact of instru- 



36 URIC ACID AS A CAUSE OF HAY FEVER. 

ments with the skin of the external auditory canal; and hay-fever 
paroxysms result from irritation of the retina, the upper lip, or the 
scalp, or from chilling the skin. 

All the facts in our possession force us to the conclusion that the 
weight of testimony is in favor of the doctrine that hay fever is a 
reflex functional nervous disease. 



URIC ACID AS A CAUSE OF HAY FEVER. 

Uric acid exists in the blood in the proportion of about one to 
forty or more of urea in health. When this proportion is disturbed by 
a relative increase of the uric acid, certain disturbances of a vascular 
and neurotic character arise. The effects of uric acid in producing 
these disturbances have been the subject of an extensive and interest- 
ing series of experiments by Alexander Haig. For years he was a 
sufferer from migraine, and studied in his own person the relation 
of uric acid to the production of attacks of this disease, and. the effects 
of anti-uric-acid treatment in subduing attacks, and of diet in pre- 
venting them. 

I have found the proportion of uric acid to urea in hay fever as 
high as 1 to 25 and 1 to 13, while 21 grains of the acid were being 
excreted in twenty-four hours. C. W. Purdy (1900) gives the propor- 
tion of uric acid to urea as 1 to 45 in health, and the secretion of uric 
acid as 6 to 12 grains per diem. Parke's "Hygiene" gives the same 
figures. Heitzman (1899) gives the proportions as 1 to 45, and 7 to 
12 grains of uric acid. Bartley's "Chemistry" (1898) gives the pro- 
portion as 1 to 40 or 50, and the secretion of uric acid as 6 to 15 grains. 
Bouchard gives 1 to 45, and 8 grains as the normal amount of uric 
acid secreted in twenty-four hours. (J. Allen Patton, Januar}', 1902.) 

First, let us consider what the effects of an excess of uric acid 
in the blood are. The disorders of the nervous system that Murchison 
associated with lithaemia are: aching pains in the limbs, lassitude,, 
pain in the shoulder, hepatic neuralgia, severe cramps in the legs, 
headache, vertigo and temporary dimness of vision, convulsions, pa- 
ralysis, noises in the ears, sleeplessness, depression of spirits, irritability 
of temper, cerebral symptoms, and a typhoid state. 

Haig maintains that the presence of uric acid in excess accounts 
for the exacerbation of pains in rheumatism and gout, and Lever con- 
tends thai these diseases are primarily due to the action of this acid 
on the brain, the spinal cord, or the solar plexus of nerves. In persons 



UKIG ACID AS A CAUSE OF HAY FEVER. 37 

suffering from intense pruritus, uric acid and the urates have been 
found in excess. 

Ebstein believes that uric-acid deposition acts as an exciter of 
inflammation in the tissues in which it is deposited. 

Quinquaud studied the effects of uric acid on the skin. He ad- 
ministered 3 to 6 grains a day to the human subject. The most com- 
mon results were boils and patches resembling eczema — the dermal 
analogue of coryza. 

Thomas J. Mays attributes attacks of angina pectoris to "the 
increased formation of uric acid, which is incidental to the gouty 
and rheumatic diathesis." He agrees with Haig in attributing mi- 
graine to the irritating effects of uric acid. 

Conklin details a number of well-marked cases of nervous, men- 
tal, nephritic, and other diseases that support the proposition that 
they are the result of the action of uric acid. 

1ST. S. Davis and others add the following to the list of manifesta- 
tions of uricacidsemia: Loss of appetite, nausea and vomiting, flatu- 
lent indigestion, diarrhoea, intense itching, asthma, blindness, deaf- 
ness, numbness of the skin and creeping sensations, hyperesthesia and 
pain in the skin, impaired memory, melancholia, delirium, epilepsy, 
and coma. 

Observe the symptoms of uric-acid irritation that are closely 
allied to paroxysms of nervous catarrh: Asthma, intense itching, over- 
sensitiveness and other nervous disturbances of the skin, neuralgia, 
sick headache, irritability of temper, etc. The first three symptoms 
often characterize attacks of nervous catarrh, and highly moral per- 
sons, like the late Henry Ward Beecher, are seized with an almost 
irresistible impulse to accompany their storms of sneezing with a 
shower of profanity. Sick headache sometimes alternates with these 
attacks, and at other times takes the place of them. 

While suffering from migraine Haig found the uric acid increased 
to the proportion of one in twenty or twenty-five of urea, whereas 
before and after attacks he found it as one to forty, and the headache 
was proportioned to the excess of uric acid over the urea, and not to 
the amount of alkali used to bring the uric acid out. The mental 
condition varied directly with the relative amount of uric acid in the 
urine. The excretion of the acid was greatly diminished before the 
attacks, — i.e., during mental exaltation. 

The author has learned, while writing upon this subject, that 
Leflaive analyzed the urine before and during attacks of hay fever, 



38 URIC ACID AS A CAUSE OF HAY FEVER. 

and found uric acid in great quantity just before the attack and half 
that quantity during the attack. Some of this may have been washed 
out of the system through the profuse perspiration that occurs during 
the violent sneezing. 

In 1893 I proposed the uric-acid theory of hay fever in the first 
prize-essay of the United States Hay Fever Association, and at the 
meeting of the American Medical Association the same year I ad- 
vocated the same theory. So far as the writer knew, he was the first 
to propose this doctrine. In 1894 it was brought to my attention 
that Shawe Tyrrel, of Toronto, had published a paper in 1892, en- 
titled "A Predisposing Cause of Hay Fever," advocating the same 
theory. Independently of each other, our studies of the subject 
forced us to arrive at the same conclusions, and I wish to accord 
Dr. Tyrrel full credit for his work. Had I known of it before 
publishing my two essays on the subject, proper reference would 
have been made to his work, since it corroborated the results of the 
experiments and treatment pursued in my practice during several 
preceding years. 

Haig says: "Uric acid in the blood contracts the arterioles and 
capillaries all over the body, producing the cold surface and extremi- 
ties, raising tension of pulse, and (according to Marcy's law that pulse- 
rate varies inversely as the arterial tension) slowing the heart. Head- 
ache is a local vascular effect of the uric acid. Excretion of this acid 
may even explain the mental depression and irritability and their re- 
sults in the excess of suicides and murders in July. There is an ex- 
cessive secretion of this acid in the warm months, and a minus excre- 
tion in cold weather. During plus excretion there will be high arterial 
tension, with anaemia of the brain, bad temper, etc. At this time a 
dose of acid would free the brain circulation from the power of the 
uric acid, and produce, as Eoy and Sherrington have shown, an in- 
crease in its size and a free flow of blood in its vessels." 

Peiper says that alkalescence of the blood is diminished in all 
fevers. Corroborative of this, Haig found, during an attack of in- 
fluenza in 1890, that there was a rise in the acidity of his blood, urine, 
and tissue-fluids, thus driving the uric acid out of these fluids, dimin- 
ishing its excretion, and causing its retention in the body. 

Bertillon says that suicides increased 40 per cent, in France after 
the influenza epidemic. This may be accounted for by the accumula- 
tion of uric acid in the body during the diminished alkalinity of the 
blood, and when the blood regained its normal alkalinity the stored 



UKIC ACID AS A CAUSE OF HAY FEVER. 39 

acid was taken into the circulation and produced its characteristic 
irritability and depressing effects. 

In health about 6 to 12 grains of uric acid are secreted every 
twenty-four hours, and it is readily soluble in the blood, which is 
slightly alkaline. If there is increased formation of this acid, no 
harm results so long as it is properly eliminated and the ratio between 
it and the urea is not disturbed. 

Haig found that by diminishing the alkalinity of the blood he 
freed it from uric acid, relaxed the arterioles, and relieved headache 
and mental depression. Increasing the alkalinity augmented the acid 
excretion, contracted the arterioles, slowed the circulation of the blood, 
and caused languor, depression, headache, and, in epileptics, a fit. 
Epilepsy, migraine, spasmodic asthma, etc., are, like neurotic catarrh, 
functional nervous diseases. What Haig says concerning epilepsy and 
migraine may be affirmed of asthma and nervous catarrh: "They may 
come on early in life, last for years or the whole of life, tend to recur 
at more or less regular intervals, are met with in members of the same 
family, and may afflict one and the same patient, — now a fit, now a 
headache, — alternating or together. Epilepsy and headache, gout 
and rheumatism are very commonly met with in the same family." 

Broadbent thinks that the convulsions of epilepsy are brought on 
by the slowing of the circulation and consequent cerebral anaemia, in 
the same way as convulsions after great haemorrhage. As we have seen, 
the effect of an excess of uric acid in the blood-vessels is to contract 
them, which, in the vessels of the brain, produces cerebral anaemia. 
This condition appears to obtain in nervous catarrh, and the attacks 
are relieved by such remedies as nitrite of amyl, etc., which relieve 
anaemia of the brain. 

The uric-acid theory of nervous catarrh is not antagonistic to 
the present status of medical opinion or surgical treatment, but, on 
the contrary, explains questions that were inexplicable before. As 
a tumor or hypertrophied bone may give rise to convulsive seizures 
in epilepsy, and as its removal may be followed by relief when no 
other structural cause exists, so in nervous catarrh, where new growths 
and other lesions of the nasal mucous membrane are present, the at- 
tack may be started by the accumulation and the suddenly setting 
free of uric acid. This precipitates the paroxysm by its irritant action, 
which finds expression in the group of symptoms characteristic of 
nervous catarrh or asthma, instead of some one of the other allied 
diseases. The particular form of manifestation may be determined 



40 URIC ACID AS A CAUSE OF HAT FEVER. 

by the growth, or seat of irritation, located in the nasal cavities. 
Where this is the only determining factor of the nature of the morbid 
symptoms, no other organic disease having resulted from the long- 
standing trouble, the removal of such a peripheral source of irritation 
may give relief from these symptoms, but it may not prevent the 
uricacida?mia from switching off into other kindred lines of disturb- 
ances if it be not corrected. 

The uric-acid theory makes clear the reasons why some persons 
suffer from attacks of nervous corvza under certain favorable condi- 
tions in winter as well as during the warm months. It also unifies 
all the various forms of ha} 7 fever. They are all variations of nervous 
catarrh. 

Patients of this class are sometimes affected more or less by func- 
tional aphasia. Haig's father suffered, from time to time for a large 
part of his life, from this trouble, and in old age had organic aphasia 
with right hemiplegia. The same functional disturbance afflicted 
Haig very markedly, at times of excess of uric acid in the. blood, with 
mental depression, letharg}', and headache. The histories of such 
cases are paralleled by the histories of nervous catarrh in many fami- 
lies. 

The periodicity of nervous catarrh has a counterpart in migraine 
that comes once in every seven, ten, fourteen, or thirty days, for years 
or for life. It may last one day or less, rarely two, and is worse in 
the morning. 

In the last published paper of the late A. Beeves Jackson he 
expressed his conviction that various neurasthenic symptoms — sleep- 
lessness, headache, vertigo, neuralgia, vague pelvic symptoms, mus- 
cular twitchings, vasomotor disturbances, etc. — are dependent really 
upon the lithic-acid diathesis. He wrote: "If this fact were duly 
recognized it would remove some of the cases from the list of those 
which are an opprobrium." 

L. C. Gray says: "Influenza, ague, and other fevers store up uric 
acid in the body." There are several causes that determine the man- 
ner in which the irritation produced by an excess of uric acid may 
express itself. These are central, peripheral, and hereditary causes. 
"The structure of the nerve-centres and the distribution of its vessels 
not only determine the kind of disturbances which uricacidaemia will 
produce in any given case, but also explain why one person suffers in 
this way from functional nervous disorders, while another, with about 
as much uric acid in bis blood and body, escapes. "When the nervous 



URIC ACID AS A CAUSE OF HAY FEVER. 41 

system is depressed by fatigue, deficient food, etc., a smaller amount 
of uric acid in the blood will suffice to produce disturbance of function 
than at other times. If uricacidamiia is prevented, the nervous sys- 
tem will not itself originate disturbances. This knowledge of the 
effects of lithsemia gives complete power to produce or remove the 
vascular conditions, and the nervous disorders which are secondary to 
(consequent upon) these conditions, by proper diet and treatment" 
(Haig). 

The arguments that apply to migraine are just as forceful in the 
case of nervous catarrh. The peripheral causes — neoplasms, hyper- 
trophies, etc. — have already been considered. 

Heredity is probably the chief factor in determining the direction 
in which the uric-acid diathesis will afflict an individual, whether it 
results in migrane, angina pectoris, asthma, nervous catarrh, or some 
other neurosis; but undoubtedly accidental- or acquired conditions 
may act as directing or localizing agents. For example of the latter 
class: a student who is predisposed to such neurosis accidentally in- 
hales the fumes of burning phosphorus in the laboratory, and this 
excites the first attack of his nervous disorder, which naturally, 
under these conditions, takes the form of asthma. On the other 
hand, many attacks of severe cold, some injury to the nose, or the 
development of a polypus may determine the nasal form of neurosis, 
or nervous catarrh. I have such cases in mind. 

We can produce and control attacks of nervous catarrh at will 
by treatment and diet, the same as we can migraine. I was first led 
to experiment with an anti-uric-acid treatment of nervous catarrh by 
my endeavors to find a solution to the problem why paroxysms of this 
disease attack sufferers regularly in the morning. These attacks come 
on about the same time, morning after morning, although the pre- 
vious afternoon and evening may have been free from suffering, and 
the night one of restful repose, with no direct access to dust-laden at- 
mosphere from without and no change in the contents of the sleeping 
apartments. The following facts appear to answer this question: 
The blood is the most strongly alkaline between the small hours of 
the morning and 9 a.m., when it reaches its greatest alkalinity. The 
more alkaline the blood, the more freely soluble is the uric acid. 
Therefore, in the morning hours the blood is the most heavily charged 
with this irritant, and during these hours patients suffer the most 
from angina pectoris, migraine, nervous catarrh, and other functional 
nervous disorders. 



42 PREDISPOSING AND AGGRAVATING CAUSES OF HAY FEVER. 

The blood is the most acid during the hours of bodily activity, 
and it reaches its maximum of acidity about midnight. During this 
time there is only a small secretion of uric acid, and the amount cir- 
culating in the blood is minute. As the blood begins to increase in 
alkalinity in the morning it dissolves the uric acid out of the more 
alkaline tissues in which it has been stored, — the liver, spleen, car- 
tilages, joints, and fibrous tissues, — and with the increasing alkalinity 
and solvent properties of the blood it becomes rich in uric acid until 
it produces the drowsiness, heaviness, or other nervous phenomena 
peculiar to any given case. 

Joal found, among 127 cases of hay-fever patients, a family his- 
tory pointing to the uric-acid diathesis in 107 cases, and in 67 cases 
among his 71 adult patients the diathesis was marked. Evidences 
of neurasthenia ivere elicited in 101 of his 127 patients. In 42 of 
107 patients of all ages the nasal mucous membrane appeared to be 
normal. 

PREDISPOSING AND AGGRAVATING CAUSES. 

Heredity and the temperaments classed as nervous are, strictly 
speaking, the predisposing causes. Broadly speaking, whatever di- 
minishes the powers of resistance predisposes one to attacks. Most 
foreign substances that are liable to come in contact with the nasal 
mucous membrane will provoke paroxysms, inasmuch as the mere con- 
tact of a polished silver probe will excite sneezing. Dust, pollen, 
infusoria; dry, hot air; cold, damp, or foggy air; smoke, gas, bright 
light from the sun, electric light, gaslight, sunlight reflected from 
snow, etc., are prolific causes. Much may depend on the character of 
the dust, for this is determined by the geological formation of any 
given locality. So wide is the distribution of dust by the varying cur- 
rents of the air that places which would naturally afford immunity 
from this disease may be visited by storms of noxious foreign pollen. 
A sea-voyage is considered a certain cure for an impending attack, 
but even there the enemy may lurk unseen in the folds of the canvas 
or clothing or in the upper currents of the atmosphere. Darwin has 
shown that pollen has been wafted many miles over the Atlantic. 
Showers of pollen have fallen hundreds of miles distant from its na- 
tive soil. Dust may be deposited in curtains, carpets, etc., and be 
retained for indefinite periods before finding lodgment in the respir- 
atory tract. The upper strata of the air may be laden with pollen, 
as they are at' times with volcanic dust, which may be so dense as to 



EXCITANTS OF HAY FEVER. 43 

darken the sky at great distances from the source of supply. These 
truths illustrate the omnipresent and occult character of the exciting 
causes. 

The greatest suffering occurs from May to October, especially in 
the country, and for the following reasons: At this season the air 
swarms with the fecundating dust of plants and flowers; the dry, hot 
air of the country is not moistened during the day except by occa- 
sional rains; the dry surface-soil affords the winds a never-failing 
supply of dust, and one is not protected from the dazzling brilliancy 
of the sun by tall buildings in the country as he may be while pur- 
suing the vocations of city life. The streets of cities are deluged with 
water in summer; the dust is laid; the air is cooled and moistened by 
evaporation. Great buildings afford protection from the scorching 
rays of the sun. The denser the population, the less the vegetation 
and the greater the relief to asthmatics and hay-fever patients. 

The irritating effect of dry, hot air causes great activity of the 
muciparous follicles and imposes a heavy burden on the glands to 
pour out sufficient mucus to keep the membrane moist. One must 
avoid dry heat from stoves and furnaces. Much-thumbed books and 
newspapers that are a little musty are exciting causes that I have not 
seen mentioned. 



CHAPTER IV. 

DISEASES OF THE NASAL CAVITIES (Continued). 

Hay Fever (Concluded). 

Symptomatology. — A reciprocal relation exists between the capil- 
lar}^ circulation of the skin and that of the internal organs, but more 
especially affecting the mucous membrane lining the air-passages. Let 
the surface of a hay-fever patient become chilled, the skin anaemic, 
the perspiration checked, and immediately there follow a correspond- 
ing hyperasmia of the mucous membrane of the respirator} 7 passages, 
an increased activity of the muciparous follicles, exquisite tickling and 
painful itching in the nose and pharynx, succeeded by violent sneez- 
ing, profuse discharge of nasal mucus, suffused and tear-bedimmed 
eyes, photophobia, a rush of blood to the head and face, severe head- 
ache, complete occlusion of the nostrils, nervous exhaustion, and such 
a desperate shaking up of the whole being as is comparable to a 
wrecked vessel in a terrific storm. But in this violent agitation of 
the body we may discern a blessing in disguise, for it restores the 
balance of circulation to the skin, the temperature rises, the sudorifer- 
ous glands resume their activity, and the skin is again bathed in per- 
spiration. At this juncture the vicarious suffering of the respiratory 
surface is relieved and the normal equipoise of functional activity 
ensues. In one who suffers from the asthmatic form of hay fever, to 
the symptoms already enumerated should be. added the characteristic 
symptoms of asthma proper. These alone make one's lot hard enough, 
but when added to the so-called "aristocratic" disease they present a 
highly colored picture of the refinement of torture. 

The sneezing is often so violent and continuous that the patient 
is scarcely able to catch sufficient breath to properly oxygenate the 
blood. The hydrorrhea is so profuse as to saturate many handker- 
chiefs — a dozen or a score in a day in severe cases. One peculiar 
symptom I have observed, but have never seen mentioned by other 
writers, is: The instant some patients begin to sneeze, they also swell 
up so that the clothes about the abdomen and waist must immediately 
be loosened to afford relief from the constriction. 

(44) 



HAY FEVER — SYMPTOMATOLOGY. 45 

These attacks come on at precisely the same time and last the 
same length of time at each recurring season. A sudden mental ex- 
citement may prevent an impending paroxysm or abbreviate one after 
its onset. The attack is as instantaneous in its invasion as asthma, 
striking one at any moment of day or night, awaking one from sound 
slumber, or taking one unawares during the pleasant engagements of 
the day, and leaving as quickly and mysteriously as it came. 

Some functional nervous diseases are transmutable, one into 
another. The author has witnessed cerebral hyperemia decline and 
disappear as hay fever superseded it, and after several years' duration 
the hay fever has, in turn, been displaced by asthma, as spasmodic 
and characteristic in its nature as the hay fever itself. Simple asthma 
may not only supplant, but may complicate it, constituting hay asthma 
proper. 

Inspection of the nasal cavities during attacks reveals the 
turbinated bodies enormously swollen and water-soaked, the mucous 
membrane very vascular, and the passages completely closed. The 
membrane is exquisitely sensitive and often painful. In .sleep it 
is necessary to breathe through the mouth, which occasions distress- 
ing dryness of the throat. The breath must be held while masticating 
or swallowing food, and with every act of deglutition the air is forced 
into the Eustachian tubes, and even particles of food seem to take the 
same course. 

In the intervals between the seasons of suffering, and even be- 
tween paroxysms from day to day, the nasal membrane may present 
no unusual appearance. Indeed, just before a seizure the nostrils may 
seem more patulous than normal, affording perfect freedom of res- 
piration. In some cases we have been unable to find any appearance 
whatever of a diseased condition between attacks. Others have the 
same hypertrophies that are common to other patients. 

There are considerable variations in the experiences of hay-fever 
sufferers, both with respect to their symptoms and the times of their 
attacks. It is very common for them to awaken in the morning feel- 
ing perfectly well, with the nasal passages comfortable and free; but 
the moment they arise and touch their bare feet to the cool floor, or 
feel the air strike the lower extremities or body, or even before rising, 
a few minutes of wakefulness are followed by sensations of dryness and 
irritation in the nose and miserable paroxysms of sneezing, as though 
they had taken a severe cold. The attack may last for a few minutes 
only, or until the morning meal with coffee, when all the symptoms 



46 ABORTIVE TREATMENT OF HAT FEVER. 

subside. The attacks may reappear at intervals during the day, with 
or without a feeling of rawness of the nasal membrane between the 
spasms of sneezing. 

Unlike the occasional sneeze of an individual who is not subject 
to hay fever, the act of sneezing is unaccompanied by any sense of 
pleasure or satisfaction. It is positively distressing, and makes the 
sufferer wretched. He is harassed by a consciousness of impatience 
and irritability of temper; his muscles act in a jerky, inco-ordinate 
way, causing him to drop things or knock them together; he must 
always be on the alert to avoid or escape those excitants of suffering 
that beset his path on every hand. 

The time these attacks usually come on is the 18th of August, 
but may vary from the 12th to the 20th in different individuals, 
although there is little, if any, variation in the case of any given 
patient. The season of suffering generally lasts until a severe frost 
occurs in September or October, when the season ends, and the refu- 
gees who have fled to the mountains or lakes of immune regions return 
to their homes to enjoy life until the following summer. In a small 
proportion of cases the attacks are more or less perennial. Exposure 
to sunlight reflected from snow, or to close, hot, impure, or dusty air 
in winter, will result in suffering. Some are attacked in June or in 
July, when certain grasses ripen and the haying season is at hand. 
The presence of roses or certain other flowers may provoke sneezing 
at any season. 

Diagnosis.— Considering the characteristics and the description 
given, the matter of diagnosis is so simple as to require no further 
mention. 

Prognosis. — Hay fever is not dangerous to life, although it causes 
serious suffering and incapacitates one for business while it lasts. It 
does not tend to disappear of itself permanently, but is amenable to 
treatment. 

Abortive Treatment. — With the uric-acid phenomena in mind, I 
attempted to break up the morning attacks of sneezing and nasal 
stenosis by doses of acid at bedtime and on first awakening in the 
morning. The experiment was a success. A series of wretched morn- 
ings was followed by freedom of respiration and a sense of well-being 
that seemed like a physical millennium. After this result of pre- 
venting the morning increase in the alkalinity of the blood, in order 
to prove the correctness of his deductions, the writer used an alka- 
line treatment, and was both delighted and disgusted with the re- 



ABORTIVE TREATMENT OF HAY FEVER. 47 

suits. The old enemy raged again, but here was clinical proof of his 
first proposition. These experiments have been successfully repeated 
until I am satisfied of the correctness of these conclusions. 

The first acid used for these experiments was the dilute sul- 
phuric acid in dose's of 20 or 30 drops in water, but, on account of the 
griping pains and diarrhoea that it produced in the early morning, 
we were obliged to substitute another. It occurred to me to try Hors- 
ford's acid phosphate that I had used for other purposes for some 
years, on the recommendation of the late Professor Jewell. 

We used teaspoonful doses of this acid without any ill effects, 
and with the result of giving complete immunity from suffering. 
One or two teaspoonfuls in a glass of water at bedtime and on first 
awakening in the morning were sufficient to break up the habit en- 
tirely. In a few days, after the symptoms ceased to appear in the 
morning, this dose was omitted. The night dose was continued until 
the habit seemed to be entirely broken up. If any nasal irritation 
reappeared, a dose or two would dispel it. By adding sugar to this 
acidulated drink it makes an agreeable lemonade, but it is better to 
avoid the sugar, and as much as possible all other uric-acid-producing 
substances. 

While the author has depended on the mineral acids to keep 
down the morning alkalinity of the blood, Bence Jones claims that 
citric acid (lemonade) will accomplish the same result. We have 
made it a point to have the morning dose well diluted with water, 
for the purpose of starting perspiration, for we have observed that 
as soon as a patient has sneezed violently enough to produce free 
sweating the symptoms either decreased or disappeared. The sweat- 
ing carries off uric acid and helps to free the blood. 

I am aware of the differences of opinion that exist concerning 
the influence of an excess of dilute phosphoric acid on the elimi- 
nation of uric acid, the effects of acid on the tubules of the kidneys, 
and the relation of a meat-and-vegetable diet to the formation of 
uric acid. We are careful to use only so much acid as is required 
to prevent the maximum of alkalinity from occurring. The acid is 
used not with the expectation of eliminating, but of clearing the blood 
of uric acid, for the purpose of preventing attacks during the season 
of suffering. If the overwrought nerves are relieved of this source 
of irritation, they are much less likely to respond to other excitants; 
and, if the morbidly susceptible condition of the nervous centres is 
due to the action of the uric acid, its oversensitiveness to all excitants 



48 ABORTIVE TREATMENT OF HAY FEVER. 

may be relieved by correcting the uricacidaemia. After relieving tho 
suffering with the acid phosphate I have produced it again by neu- 
tralizing the acid with an excess of bicarbonate of sodium and em- 
ploying the usual doses. This converted the acid into a ready solvent 
of uric acid, flooded the blood with it, and produced the attacks. 
In turn, I have followed this up with the acid, relieved all the ca- 
tarrhal symptoms by precipitating the uric acid from the blood into 
the tissues, and produced the characteristic gouty pains. Again, by 
substituting drachm doses of phosphate of sodium for the acid I have 
precipitated all the symptoms of a severe nasal catarrh. 

Some other remedies produce effects parallel to the acid treat- 
ment. Nitroglycerin, nitrite of sodium, nitrite of amyl, antipyrin, 
etc., have a similar effect. Opium raises the acidity of urine, dimin- 
ishes the alkalinity of the blood, and reduces the amount of uric 
acid, It relaxes the arterioles and improves the circulation of the 
brain. Iron and lead have a similar effect. Mercury reduces the ex- 
cretion of uric acid, reduces tension of pulse, and produces diuresis. 
If opium is employed, its ill effects should be prevented by' following 
up its use with salicylate of soda for a few days to free the system 
of uric acid. Quinine, so generally used, is contra-indicated, for, 
according to Quain, it brings uric acid into the blood. 

There is one remedy that has proved, in my hands, invariably 
unfailing in giving relief, especially when given at the beginning of 
an attack of nervous catarrh or common colds. It is for temporary 
use only, like the acid treatment. The author has employed it for 
the last twenty years or more, but in this case it is, like old wine, 
the better for age. This is a combination of atropia and morphia, 
in the proportion of 1 part of atropia to 50 of morphia. The ordi- 
nary adult dose is from 1 / 16 to 1 / 8 grain of this mixture, according 
to the severity of the attack. It may be repeated in an hour or two, 
if the first dose does not entirely relieve the sneezing, running at the 
nose, and stenosis. I do not believe it has ever failed to stop an attack 
when properly adapted to the case. No person has ever acquired the 
drug habit through my prescribing it. I never write a prescription 
for it nor allow a patient to know the composition of the remedy, — 
not for mercenary purposes, for it is more often given away than 
charged for, but in order to obviate the possibility of being responsible 
for a drug habit. The morphia clears the blood of uric acid, dimin- 
ishes the nervous irritability, suppresses oversecretion from the mu- 
ciparous glands, and stimulates the circulation and activity of the 



LOCAL SELF-TREATMENT OF HAY FEVER. 49 

nervous centres, while the atropia elevates the tone of the blood- 
vessels, quickens the pulse, decreases all the secretions except the 
urine, sustains bodily temperature, stimulates the respiratory centre, 
counteracts the constipating effect of the morphia, and acts as an 
antispasmodic. Caffeine, 1 / Q grain, may be added to this dose to 
stimulate the nervous centres and kidneys. (See coryza tablets, 
page 21.) 

Local Self-treatment. — The most useful self-treatment probably 
is (1) the use of a convenient pocket-inhaler (Fig. 23) that I have 
devised for patients who take cold easily. It is called the "camenthol 
inhaler." It can be used in an inconspicuous and expeditious man- 
ner in public places, where it would be impracticable to combat a 
sudden seizure with other and slower measures. Several gentle, pro- 
longed inhalations should be taken through one nostril while the 
opposite one is closed, until the irritation is relieved. The breath 
should not be allowed to pass back through the inhaler, but through 
the mouth instead. The camphor-menthol does not become irri- 
tating to the membrane, like menthol alone, after having been used 
a considerable time. It is blander and more soothing than the men- 
thol crystals, iodine, or carbolic acid. When the throat is involved, 
it can be inhaled through the mouth for self -treatment. (2) For home 
treatment, morning and night, I usually prescribe a solution of cam- 
phor-menthol in lavolin, to be sprayed into the nostrils and throat. 
The 1- and 3-per-cent. solutions are the most satisfactory. It is best 
to begin with the weaker, and increase gradually to the 3-per-cent. 
solution. 

Joseph A. White applies a much stronger solution than the last 
named in the asthmatic type. He first applies a 4-per-cent. solution 
of cocaine, and follows this with camphor-menthol, of which he gives 
the following formula (Burnett, vol. ii, p. 126): Menthol, gum cam- 
phor, of each, gr. xxx; liquid cosmolin, §j. (The quantity of liquid 
cosmolin was printed as a drachm, but an ounce was probably in- 
tended.) However, this is about four times as strong as this very sensi- 
tive class of patients will generally tolerate with equanimity unless 
preceded by cocaine, and liquid cosmolin is not as bland a vehicle as 
lavolin, benzoinol, or albolene, all of which have been deprived of the 
irritating properties characteristic of cosmolin when applied to the 
nasal mucous membrane. 

Excellent results have been reported from the local application of 
solutions of suprarenal extract during attacks to contract the blood- 



50 PREVENTIVE TREATMENT OF HAY FEVER. 

vessels and shrink the tumefied tissues. Although the writer has em- 
ployed this remedy, with chloretone as a preservative, in hay fever 
with somewhat less gratifying effects than others report, it will require 
more time to fix its value. Combined with cocaine it gives a certain 
amount of prompt relief, but the danger of establishing the cocaine 
habit militates against the use of such a formula. While the supra- 
renal solution relieves the nasal stenosis temporarily, it does not re- 
move the cause of the stenosis. 

Preventive Treatment. — The treatment to eliminate uric acid 
cannot be undertaken to advantage during the season of attacks, ex- 
cept so far as relates to diet and the use of lithia. Haig does not 
believe that excessive uric-acid formation takes place; but, from a 
considerable study of this subject, I am forced to the conclusion that 
an excess of uric acid in the system is not due alone to continued re- 
tention and storage of the small normal overflow by the renal vein, 
but to an increased formation also. In a conversation with X. S. 
Davis, that eminent authority corroborated the latter view. It fol- 
lows, then, that it is necessary to reduce as much as possible the use 
of those foods that increase the actual formation of uric acid, such 
as meats, sweets, beer, wine, etc., and limit the diet largely to fruits, 
vegetables, milk, etc. 

Exercise also aids in the excretion of uric acid, although there 
may be an actual increase in the amount of acid. Lange treats peri- 
odical mental depression successfully by reducing the amount of food 
and by systematic exercise. 

A diet of milk with occasional very small quantities of egg and 
fish, with no other animal food, will prevent suffering from sick head- 
ache entirely, without medicinal treatment. With this diet the nat- 
ural ratio between uric acid and urea — 1 to 40 — is maintained. Haig 
claims that, by a uric-acid-producing diet, one can store up in the 
body several ounces of uric acid in a few years, or, by a correct diet, 
not as many grains. He has been on such a diet over eight years with 
very seldom a headache. By eating meat and drinking wine two or 
three days in any single week, he is sure to bring on the migraine. 

A course of salicylate, salicin, lithium, etc., will remove the excess 
of uric acid. If an alkali is given it is likely to produce uricacidsemia 
and precipitate an attack of the trouble we are endeavoring to pre- 
vent. For an attack, then, a dose of acid should be given to free the 
blood of uric acid; then the salicylate of sodium should be given for 
two or three days or longer, to sweep it out of the body; but the 



PREVENTIVE TREATMENT OF HAT FEVER. 51 

salicylate should not be given during the attack, for it may aggravate 
the symptoms. 

For a fortnight or a month, perhaps longer, preceding the regu- 
lar season of attacks of nervous catarrh, from 2 to 6 grains of the 
salicylate should be given every day or two, in order to get and keep 
the quantity of the acid in the body down to the normal amount. 
The copious use of the stronger lithia-waters is advantageous, also. 
The 5-grain tablets of the effervescing citrate of lithia are excellent, 
and the same may be said of alkalithia and the effervescent citrate of 
lithia, soda, and potash. The writer now depends almost entirely 
upon lithia as a preventive remedy. 

Since about the year 1890 I have employed carbonate and citrate 
of lithium as well as various preparations of sodium, potassium, and 
magnesium for preventing attacks of hay fever when uricacidgemia 
undoubtedly was present. The success of daily, small doses of lithia, 
averaging 10, 15, or 20 grains per diem in morning and evening doses 
evenly divided, led me to the conclusion that other remedies that 
would keep the blood and urine alkaline might prove beneficial. Lithia 
prevented attacks that were impending or relieved those that were 
already causing distress, and it also averted attacks after indiscretions 
in diet, when a full dose was taken just after a meal of meats and 
sweets. The great number of times that these experiences were re- 
peated left no room for doubt of the correctness of our deductions. 

Sodium sulphate and bicarbonate, potassium sulphate and bicar- 
bonate, and magnesium were then tried in doses of 5 and 10 grains, 
administered in the same manner in which lithia had been employed, 
with liberal quantities of water. While the results have been en- 
couraging, the experience with these salts as preventive remedies has 
been so much less than with lithium that it is not yet possible to speak 
with the same amount of confidence regarding them as in respect to 
the lithium salts. 

This treatment, combined with proper diet, should be successful, 
provided that there is no organic disease of the structures, central 
or peripheral. Any organic disease — hypertrophy, polypus, etc. — must 
receive such attention as to secure the harmonious co-ordination of all 
the functions, for this treatment is directed against uricaeidaemia 
only, as a cause of suffering; but it should not be forgotten that there 
are other causes that may operate to produce attacks, just as in the 
case of spasmodic asthma arising from bronchitis, irritating gases, and 
other excitants. 



52 PREVENTIVE TREATMENT OF HAY FEVER. 

In this connection it is worth while to note the apparent effect 
of an operation on the ear in relation to hay fever. In June, 1897, 
I removed an aural polypus and the ossicles, and curetted granula- 
tions of the middle ear under a 20-per-cent. cocaine anaesthesia in 
a case of long-standing chronic suppuration. The patient, who was 
an educator, was a hay-fever sufferer. Heretofore the attacks had 
come on in June and lasted until the frosts of fall. In November, 
1897, the patient, who lives a considerable distance from the city, 
called and informed me that the operation had relieved her from hay 
fever, for she had escaped it entirely the past summer. The sup- 
jDuration ceased; but whether the freedom from hay fever was a con- 
sequence or a coincidence is a debatable question. 

The author is of the opinion that, with the present theory, im- 
proved therapeutics, and proper diet for this disease, the medical pro- 
fession need no longer say to hay-fever patients, in a patronizing way, 
"Suffer, little children, for of such is the kingdom of heaven." But 
we must recognize and combat the uric-acid diathesis if we would 
bring comfort to these patients and obliterate a stigma that dims the 
lustre of our great art. 

H. H. Curtis has published reports of a few cases of hay fever 
treated with ragweed. He believes that the cases due to ragweed may 
be prevented by giving from 2 to 10 drops of the tincture or fluid ex- 
tract of ambrosia artemisiasfolia (ragweed) three times a day during 
the two weeks preceding the paroxysm. While the results were gen- 
erally good, in some cases reported there was utter failure. It is 
thought probable that these may have been due to goldenrod or other 
plants. In such cases the immunizing drug should be of the same kind 
as that which caused the trouble. He concludes that those dependent 
entirely upon ragweed make up about 60 per cent, of the cases. When 
there is a mixed infection and a preponderance of asthmatic symp- 
toms, a nasal spray of suprarenal extract may be used with benefit. 
(Western Medical Review, September 16, 1901.) 

The possibility of producing an antitoxin for hay fever has been 
made the subject of investigation by Dunbar, who is an American 
physician and the director of the Hygienic Institute of Hamburg. 
The results of his experiments coincide in some respect? with those 
of Curtis, and differ in others. The former lias apparently demon- 
strated that the pollen of many cereals, such as corn, wheat, r\e, and 
oats, and <>!' grasses, contains an active principle which is soluble in 
the secretions of the nose, eves, and mouth, and in the blood-serum, 



HAY FEVER MEDICAL OPINIONS. 53 

and which excites the irritation and characteristic paroxysms of hay 
fever and asthma. The fact remains that these irritants affect only 
those who are by predisposition particularly susceptible to them, and 
this predisposition remains still inexplicable. Such persons exhibit 
their susceptibility even when the starch rodlets of the pollen are 
injected hypodermically, and symptoms of coryza, conjunctivitis, and 
bronchial asthma develop. 

Naturally these phenomena suggested to Dunbar that immuniza- 
tion might be possible by means of a curative serum. Carrying out 
this idea, he injected ainmals with pollen toxin, and in time obtained 
an antitoxin serum. On applying this antitoxin to the nose or eyes 
of persons who had been infected with pollen for a short time the 
irritation ceased, and it rendered pollen ineffective after being mixed 
with it in test-tubes. 

The fact that the neutralizing effect of the antitoxin serum holds 
good only in cases in which it is applied shortly after the infection 
occurs should not discourage further efforts to produce a more ideal 
serum. An especially interesting deduction of Dunbar, differing 
from that of Curtis, is that the toxic principle of the various pollens 
is identical, since the injection of antitoxin obtained from one kind of 
pollen will neutralize the effect of pollen from a different plant. 

So far as these facts affect the subject of hay fever and pollen as 
an exciting cause they seem to hold out promise of relief, and it is 
to be hoped that Dunbar's seven years of work in this line may be 
crowned with success; but it is a complex subject, and each case is 
a problem to be solved by itself. (The Illinois Medical Bulletin, 
August, 1903.) 

MEDICAL OPINIONS. 

We have written to a large number of specialists and writers on 
this subject to obtain their latest views and treatment. There were 
some whose recent publications made it unnecessary to write, and 
others who were inaccessible; so we have in such cases searched the 
literature and endeavored to present a fair and impartial account of the 
present status of medical opinion on the nature and treatment of hay 
fever. From some articles it is impossible to gather any definite 
knowledge of the opinions of the writers on the nature of the disease; 
we have stricken out much for that reason, but have, in every case pre- 
sented, striven to give a natural and unbiased interpretation of the 
author's views. The methods of treatment often indicated these. The 



54 HAY FEVER — MEDICAL OPINIONS. 

opinion of each writer on the pathology, whether he believes it to be a 
neurotic or local affection, is indicated by a single word following his 
name, — neurosis or local. 

E. L. Shurly. Neurosis. "I am very glad that you will present the 
subject of the treatment of hay fever. It is a very important one, and does 
not receive the intellectual attention which it deserves. It is my belief that 
some cases can be relieved by counterirritation in almost any part of the 
body, as well as in the nasal passages. I also believe that its purely nasal 
origin is overestimated. I have found snuff of daturine with starch some- 
times more effective than the galvanocautery." He uses tincture of iodine, 
etc., over the neck and chest, as recommended by Faulkner. If there arc new 
growths he removes them. 

W. E. Casselbeeky. Neurosis. "I believe hay fever to be amenable to 
thorough surgical treatment, establishing a complete cure in a minority of 
cases only, — those particularly which present gross deformities of the septum 
and the turbinates, and polypi. In the large majority the condition can be 
materially mitigated, the degree of improvement being in accordance (1) with 
the degree of structural disease present in the nose and (2) with the thorough- 
ness of the treatment. A small minority are not amenable to surgical treat- 
ment. They include the highly neurotic individuals in whose noses, between 
the paroxysms, little or no structural change is apparent. Much can be ac- 
complished toward palliation by both systemic and local medicinal treatment. 
But in my experience medicinal treatment is nearly, if not quite, powerless to 
effect a permanent cure. Such, however, may take place in the course of years, 
perhaps, assisted by supportive and tonic treatment, as the individual's gen- 
eral health improves and the neurotic element lessens. Of local palliative 
remedies, cocaine is probably the most powerful and at the same time the 
most dangerous remedy. Its use and sale should be regulated by law." 

C. H. Knight. Neurosis. Destroys all enlargements. "When it is im- 
possible to define a distinct abnormality, the nasal, membrane throughout 
being sensitive and irritable, good results seem to me to follow painting the 
mucous membrane with a solution of perchloride of mercury, muriate of 
quinine, and glycerite of carbolic acid. Of course, general treatment is always 
essential. 1 must confess that my proportion of cures is small. I feel quite 
pleased if I succeed in mitigating the severity of the symptoms and lessening 
their duration, etc." 

\\ . C. Glasgow. Neurosis. "Surgical treatment has given little or no 
permanent relief. Symptomatic treatment will ameliorate the symptoms and 
keep the patients in comparative comfort during attacks. The constitutional 
treatment with potassium iodide, belladonna, antipyrin, etc., lessens the dis- 
turbance and sometimes controls it." 

Jonathan Wright. Neurosis. "I have seen several cases with no ap- 
preciable intranasal lesion except the acute condition during the attack. I 
have operated a few times for intranasal lesions of various kinds. All were 
improved somewhat, — some markedly, some slightly. My impression is that 
the relief in these cases is too limited to make it of value." 



HAY FEVER MEDICAL OPINIONS. 55 

R. W. Seiss. 'Neurosis. "Operations in the nose should be resorted to 
cautiously, and only when absolutely necessary." He recommends strychnine 
and bromides internally, and benzoate of sodium, 10 to 20 grains to the ounce, 
or menthol, 10 to 30 grains, for a spray. 

E. J. Kuh. Neurosis. A sufferer from hay asthma. He found the most 
relief from the following spray: Camphor, y, part; menthol, 1 part; creasote, 
1; oil of eucalyptus, 2; oil of pine-needles, 2; albolene, 93 1 / 2 parts. 

J. 0. Roe. Local. He believes that there is always a diseased condition 
of the nose causing hay fever. These diseased tissues must be removed or 
destroyed. He denies the neurotic character of the disease. He says: "Irrita- 
tion reflected from other situations to the nasal chambers is not hay fever/' 

F. H. Bosworth. Neurosis. He believes that intranasal surgery affords 
permanent relief. This method is clear in its indications, easy of accomplisn- 
ment, and promises not only more immediate, but more permanent, relief than 
any other method. He believes that hay fever and spasmodic asthma are 
pathologically identical. 

J. N. Mackenzie. Neurosis. Better results were obtained from consti- 
tutional than from local treatment. He gives zinc, nux vomica, quinine, and 
arsenic. 

W. H. Daly. Local. He believed it to be simply a deformity in the 
nose, and that a large proportion of cases could be cured by surgical opera- 
tions. 

J. Solis-Cohen. Neurosis. Any local nasal trouble may be simply inci- 
dental. He prescribes tonic treatment and restricts the use of meat. 

Kitchen, of New York. Local. He believes it is due to the membrane 
being deficient in the epithelial covering, etc., that calls for local remedies. 

B. O. Kinneae. Neurosis. He believes it to be due to irritation of the 
gray matter composing the centres of the fifth, glossopharyngeal, the facial 
nerves, and some of the pneumogastric. He found that treatment addressed 
to this condition was successful. He used the well-known icebafs of J. Chap- 
man, of Paris, along the spine between the shoulders, from the fourth cervical 
to the third dorsal vertebra, to dilate the arterioles of the whole body, thus 
evenly distributing the circulation and withdrawing the blood from the con- 
gested centres. The applications lasted from sixty to ninety minutes, one to 
three times a day. 

M. R. Brown. Neurosis. The supersensitive areas should be destroyed 
with the cautery. Atropine, Vioo grain, once or twice daily or a 4-per-cent. 
solution of cocaine locally may give temporary relief. 

H. H. Curtis. Neurosis. He sears the enlarged tissues with chromic 
acid in preference to all other escharotics. 

C. E. de M. Sajous. Neurosis. He believes that if cauterization fail to 
cure, it is because it is not carried deeply enough. He uses glacial acetic acid 
or nitric acid, and he gives strychnine and coca-wine after meals. 

William Cheatham, of Louisville. Neurosis. He praises antipyrin in 
10 to 30 grains; also acetanilid, 4 to 6 grains a day. 

T. M. Hardie. Neurosis. He believes that operations will benefit a large 
proportion, but constitutional treatment is necessary in most instances. 



56 HAY FEVER MEDICAL OPINIONS. 

Beverly Robixsox. Neurosis. Soothing applications and constitutional 
medication. He advises against surgical interference except when there are 
positively diseased growths. 

I. Gluck. Local. He believes the nervous element to be a result, instead 
of the cause, of the disease. He uses a 10-per-cent. solution of atropine after 
anaesthetizing with cocaine-phenol. He gives aconitine every hour or two, 
affording relief and aborting attacks in from two to five days. 

Carl Seiler. Neurosis. He uses sprays of cocaine and plugs of cotton 
saturated with it. A sponge worn in the nose to filter the air is recom- 
mended. Quinine in large doses is advised and tonics and atropine for the 
fever. In the later stages iodide and bromide of sodium are given. Morphine 
hypodermically is advised. All enlargements should be removed; he gives 
dilute phosphoric acid, 30 drops a day. 

De Lamalleree. Neurosis. He believes it is a neurosis of nasal origin, 
and claims to subdue morbid sensitiveness of the membrane by douches of car- 
bonic-acid gases locally for fifteen minutes at a time, three times a day. 

Sir Axdrew Clark. Neurosis. He resorts to constitutional remedies 
and applies to the nostril with a camel's hair pencil this mixture: 1 ounce 
each of glycerin and carbolic acid, 1 drachm of quinine, and 1 / 2000 part of the 
perchloride of mercury. Heat must be used to dissolve the quinine. 

P. McBride. Neurosis. He treats it as a nervous disease, and if this 
fail he uses cocaine and the galvanocautery. He deprecates indiscriminate 
cauterization, however. 

D. B. Lees. Neurosis. He claims to abort it with bromide and bella- 
donna. 

Johx North. Neurosis. Employs anti-uric-acid treatment, and removes 
hypertrophies, with satisfactory results. 

Gouguexheim. Neurosis. He uses nervines, and cocaine locally. 

The author operates with the electrocautery or by other methods when 
there are indications for such measures. 



PLATE III. 



PLATE III. 



Figure 1. — Male, set, 21; anterior view of extensive osteo-enchondroma of sep- 
tum, completely occluding left nasal cavity; mass reduced with dental engine. 
Figure 2.— Lateral view of above. 

Figure 3.— Posterior view of asymmetrical nasal cavities of above case; com- 
plete stenosis of the left naris. 

Figure 4. — Male, set. 44; anterior view of deviation of septum to right, causing 
partial occlusion of cavity. 

Figure 5. — Lateral view of above, showing concavity of septum anteriorly and 
a convexity posteriorly, due to abnormal thickness of the septum. 

Figure 6. — Posterior view of above, showing the thickened septum pressing on 
left middle and inferior turbinated bodies, causing asthma. Thickness reduced with 
surgical engine, passing burr under the mucous membrane; asthma relieved. 

Figure 7. — Male, set. 48; relaxation of soft palate, causing symptoms of elon- 
gated uvula; astringents found useless; amputation of uvula. 

Figure 8. — Female, set. 22; elongation of uvula, causing cough, expectoration, 
etc., and general symptoms of phthisis; amputation; complete relief. 

Figure 9. — Female, set. 27; position of mouth in forcible separation of jaws 
during tonsillitis; further examination impossible; diagnosis established by char- 
acter of pain, color of tongue, odor of breath, and dysphagia. 

Figure 10. — Male, set. 28; hypertrophy of the tonsils; amputation with ton- 
sillotome. 

Figure 11. — Appearance of tonsils in above case during an attack of tonsillitis. 



[Note. — Represented as seen by gaslight. By daylight the red color appears much 

paler.] 



PLATE 111, 




CHAPTER Y. 
DISEASES OF THE NASAL CAVITIES (Continued). 

Hypertrophic Rhinitis. 

Pathology.; — In this form of nasal catarrh there is not only a 
thickening of the mucous membrane, but also an increase of connect- 




Fig. 25. — Nasal Synechia. (Author's Specimen.) Point of probe is in- 
serted between the inferior turbinated body and the projection 
of the septum at the point of their union. 

ive-tissue formation in the submucous layer, or corpora cavernosa. 
The venous sinuses, having passed through the stage of vasoparesis, 
have now become permanently dilated. The newly formed fibrous 
tissue prevents their contraction and maintains them rigidly dilated 



58 



HYPERTROPHIC RHINITIS. 



until pressure upon their walls by contraction of this tissue, the pres- 
ence of leucocytes, or the formation of connective-tissue septa and 
thrombi within the sinuses finally obliterates them. 

During the hypertrophic stage there is increased vascularity of 
the turbinals and of the septum. The most frequent situations of 
thickening of the membrane and tissues beneath are the posterior ends 
of the turbinate bodies (Plate IV and Figs. 27 to 30). Depressions 
and spurs of the septum nasi, ecchondroses and exostoses, and sig- 
moid deflections resembling corrugations are frequent accompani- 




Fig. 26. — Posterior View of Osseous Bridge Shown in Fig. 25. 
(Author's Specimen.) 



ments (Plate III). Occasionally adhesion occurs between the septum 
and turbinals, forming a bridge, or synechia (Figs. 25 and 26). 

Etiology. — This is a sequel of simple chronic rhinitis. 

Symptomatology. — The obstruction to the free passage of air 
through the nose, by great thickening and deformities of the turbinals 
and the septum, causes partial or complete mouth-breathing. Patient* 
complain that they take cold easily and that when lying on one side 
the lower nostril closes. The latter symptom occurs in consequence 
of the blood gravitating to the lower turbinals and causing thorn to 
swell. A slight exposure results in stenosis of both nostrils, and as 



HYPERTROPHIC RHINITIS. 



59 



a result the constant passing of air through the throat instead of the 
nose dries the throat and larynx and gives rise to more or less irrita- 
tion or inflammation of these parts. 

When the stenosis is marked the nasal voice is a characteristic 
sign. Invasions of the nasal ducts and Eustachian tubes lead to in- 
volvement of the conjunctivae and the middle ears. Watery eyes, 
impairment of hearing, and tinnitus aurium are common sequels of 
this disease. When the very young are affected the pharyngeal and 
oral tonsils are often found hypertrophied (Plates I and III) and 
require excision. Anosmia (absence of the sense of smell) and im- 




Fig. 27. — Transverse Vertical Section through the Vault of the Pharynx 

and Eustachian Tubes. 1, Posterior border of the vomer. 2, 

Eustachian tube. 3, Inferior turbinated body. 



pairment of taste are occasional symptoms. When headaches are pres- 
ent, they are referred to the supra-orbital or frontal region. 

Asthmatic attacks are sometimes due to pressure of the enlarged 
turbinals against the septum (Fig. 56). The secretions, which are 
much more abundant than in health and more copious in the morn- 
ing on account of their accumulation during the sleeping-hours, cause 
a disagreeable habit of hawking and hemming to clear the throat, 
especially on rising in the morning. 

Diagnosis. — The septum, like the turbinals, is red and thick- 
ened, particularly near its base. The turbinals, instead of presenting 



60 



HYPERTROPHIC RHIXITIS. 



a smooth, glassy surface, as in the simple form, are hypertrophied 
unevenly and sometimes present a somewhat nodular appearance. 
The inferior turbinate body usually shows the greatest enlargement, 
but the middle one is often found in contact with the septum. Their 
posterior extremities may blossom out into berry-like buds of a gray 
or purple color (Plate IV). The former are the commoner. Probe- 
pressure meets with a firm, instead of a yielding, resistance. 

Prognosis. — After middle age the hypertrophies generally become 
absorbed and disappear, when this form often merges in atrophic 
catarrh. The hearing is likely to suffer, and there is a strong pre- 




Fig. 28. — Transverse Vertical Section through the Posterior Nares. 
Sphenoid antra. 2, Posterior end of the inferior 
turbinated bodv. 



1, 



disposition to catarrhal affections of the pharynx and larynx. Mod- 
ern methods of surgical treatment afford an excellent prognosis. 

Treatment. — Cleanliness is of prime importance in this as in 
other forms of nasal catarrh. The solutions and methods given in 
treating of the simple form are indicated here, but medicinal treat- 
ment alone will not suffice to remove hypertrophies. Operative meas- 
ures must be brought into requisition. Of these the electrocautery 
is now the most frequently resorted to except for cartilaginous and 
<>— cous outgrowths, which require the knife, saw, or the trephine. 
For the fibrous growths the hot or cold snare, scissors, chemical 



HYPERTROPHIC RHINITIS. 



61 



caustics, etc., are employed. "We will first consider the electrical ap- 
paratus. 

For physicians who practice in the country, where the incan- 
descent electric lights are not a part of their office equipment, the 
Wabash cautery-battery (Fig. 31) is satisfactory. It has the ad- 
vantage of a mechanism which prevents the immersion of the zinc 
and carbon elements in the cautery fluid except when in use. This 
extends the life of the battery very materially. By keeping a fresh 
supply of the fluid on hand for immediate use one need never be 




Fig. 29. — Transverse Vertical Section through the Orbits, Nasal Fossae, 
and Maxillary Antra. (View from Behind.) 1, Ethmoid cells. 2, Superior 
turbinated body. 3, Middle turbinated body. 4, Antrum of Highmore. 5, 
Inferior turbinated body. 6, Embryonic tooth. 



disappointed by the battery's not working. The Flemming battery, 
also, is effective. 

If the physician's office is wired for incandescent electric lights, 
or if he is not remote from conveniences for storing his battery, the 
one shown in Fig. 32 is to be recommended. It is more easily port- 
able than the fluid battery, and will give a white heat. Unlike the 
plunge battery, it deteriorates in consequence of disuse, and is better 
for being worked at least three times a week. When lying idle it 
sulphates; that is, sulphate of lead forms on the plates and renders 
it inoperative. 



62 



HYPERTROPHIC RHINITIS. 



The most thoroughly useful combined electrocautery and motor 
instrument with which the author has had any experience is the 
rotary current-transformer and dynamomotor shown in Fig. 33. 
Above the transformer is seen the switch, and at the left are the 
cautery-rheostat and cautery-handle, with the cautery-snare, ready 
for use with the 110-volt direct current, such as is used in Chicago. 

The cautery-current furnished by this transformer has an electro- 
motive force of 7 1 / 2 volts and a volume sufficient to heat the largest 
cautery-electrode, and it is perfectly controlled by the rheostat; so 







Fig. 30. — Transverse Vertical Section through the Nasal Fossae. (View 

from Behind.) 1, Ethmoid cells. 2, Deflection and spur of septum 

with adhesion to the left inferior turbinated bodv. 



that the operator has at command and under entire control the full 
range of any desired strength of current. This transformer is quiet 
in its operation, and it may be placed in the treatment-room or in 
any convenient location at a distance from the operating chair by 
extending the wires leading from the generator to the rheostat. It 
has given entirely satisfactory service in my work both for cautery 
purposes and for operating drills, burs, etc., in connection with the 
dental arm. For the perfecting of this superior apparatus I am under 
obligations to C. S. Keiswanger, and the Mcintosh Battery and Op- 
tical Company, of Chicago. 



HYPERTROPHIC RHIXITIS THE ELECTROCAUTERY. 



63 



In many of the smaller towns the electric current employed for 
the purposes of illumination is of the alternating kind, and is trans- 
formed for house and office purposes to a pressure of 52 or 104 volts. 
When this current is obtainable it is much cheaper, and more easily 
adapted to cautery uses, than the 110-volt direct current. 

A transformer for this current is illustrated in Fig. 34. The 
current from the mains enters the binding-posts on the side of the 
instrument, and by flowing through a magnetizing coil consisting of 
a large number of turns of fine wire, induces a rapidly reversed flow 
of magnetism through a centre bundle of soft-iron wires. This flow 




Fig. 31. — The Wabash Cautery-battery, with Electrodes, Lamp, and Handles. 

of magnetism encircles the secondary coil, which, consisting of a few 
turns of very coarse wire, delivers a current of low voltage and high 
amperage to the binding-posts on the top of the instrument. 

By means of the hand-wheel on the transformer the secondary 
coil may be raised out of the magnetic field of the primary, thus 
diminishing the current supplying the cautery-electrode. In this 
manner the current is placed under absolute control; and so perfect 
is the adjustment that a fraction of a turn of the wheel raises or 
lowers the temperature of the cautery-knife a perceptible degree. The 
voltage of the current obtained may be varied at will from 2 to 12 
volts, and it may be utilized for lighting small lamps. 



64 



ELECTROCAUTERY APPARATUS. 



The transformer, when heating the largest cautery-knife, takes 
from the mains about 2 amperes, and delivers to the cautery-knife 
40 amperes. The large increase of current in passing through the 
transformer is offset by a corresponding diminution of voltage. A 
large volume of current at a low voltage is what is required for cau- 
tery purposes. 

Figs. 31 and 35 show several of the most useful cautery-elec- 
trodes, and Fig. 36 shows a convenient handle. One must select the 




Fig. 32. — The American Storage Battery. 

electrode according to the individual requirements of each case. The 
electrodes should lit into the handle in such a way as to permit the 
operator's arm to rest naturally by his side while cauterizing, the same 
as while using the nasal speculum (Fig. 3). They are not now so con- 
structed, but they should be. 

If the physician does not happen to have the conveniences of the 
electrocautery, he may resort to chromic, or nitric, or monochloracetie 
acid. Of these the chromic acid possesses decided advantages over the- 









ELECTROCAUTERY DYNAMIC-MOTOR. 



65 



others. It is fusible into an easily manageable bead on the chromic- 
acid applicator (Fig. 182). To accomplish this, the platinum loop is 
dipped into the dry acid crystals and held over a small name to heat. 
As soon as the acid begins to melt it is quickly withdrawn from the 




Fig. 33. — Electric-current Transformer and Dynamomotor. 

flame and blown upon to cool it rapidly into the form and size of 
bead desired. One should be careful not to apply the acid on a very 
moist surface too long, or moisture will be absorbed sufficiently to 
loosen the bead and allow it to fall off the loop, and thus cauterize 



66 



ELECTRIC-CURREXT TRANSFORMERS. 



tissue that does not need it. In the use of liquid acids all the sur- 
plus fluid must be pressed out of the cotton pledget by which it is 
applied before introducing it into the nose, otherwise it will spread 
over the surrounding surface. 

Before any operation the part to be attacked should be rendered 
antiseptic. The writer applies a solution of suprarenal gland before 
treating the field of operation with cocaine, in order to render the 
operation bloodless, and to lessen the liability to any distressing mani- 
festations of the cocaine. 




Fig. 34. — Alternating Electric-current Transformer for Cautery Purposes. 

Fifteen minutes before cauterizing the mucous membrane an 
8-per-cent. solution of cocaine hydrochlorate is to be applied. It must 
not be sprayed into the nose, for toxic effects and even collapse may 
result from an overdose. It is best to twist a piece of absorbent cotton 
loosely on the carrier (Fig. 115), dip it into the anaesthetic solution, 
and then adjust it nicely to the particular area wo desire to cauterize 
and slip it off the carrier, leaving it pressed lightly between the septum 
and turbinal. Like the liquid acids, all the surplus of the anesthetic 
solution should be pressed out in the mouth of the medicine-container 
before introducing it. The patienl is directed not to swallow any that 
may trickle into his throat. In about fifteen 'minutes the tissues 



ELECTROCAUTERY INSTRUMENTS. 



67 



should be sufficiently anaesthetized to burn without pain. It need 
hardly be repeated that the membrane must be thoroughly cleansed 
and dried before the treatment, for if thick discharges are present they 
prevent the action of the drug upon the tissues as well as weaken it by 
dilution. The patient should incline his head forward to prevent the 
cocaine from entering his throat. 

It is useful to instruct the patient to raise his hand if he should 
begin to experience any severe pain from the cautery, However, by 
employing a strong preparation of the anaesthetic and leaving it a 
considerable time, even twenty minutes, in contact with the membrane 






Fig. 35. — Cautery-knife. 

by means of the cotton pack, it is possible to burn deeply without 
causing much discomfort. There is an advantage in cauterizing 
deeply. As cicatrization takes place a furrow forms, which, together 
with the subsequent contraction, leaves a capacious breathing-space 
between the turbinate body and the septum. 

The electrode should be used at a white heat, with care that it 
does not melt, or burn out, and it must not be allowed to cool while 
in contact with the tissue, for if it does it tears away the burned 
parts during its removal, and leaves a raw, unprotected, bleeding 




Fig. 36. — Mcintosh Electrocautery Handle, with Snare and Windlass. 
It answers for snaring as well as for holding electrodes. 

surface. It must be removed while it is still hot, care being taken to 
avoid touching any but the anaesthetized area. If the electrode is 
permitted to touch the border of the naris in its withdrawal, the re- 
sulting burn will cause much annoyance. 

Only a small area should be cauterized at one treatment. Not 
more than one-third or less of the turbinate body should be treated 
at a single cauterization, for if more is included the reaction occa- 
sions considerable swelling, a copious serous discharge, pain, headache, 
irritation of the corresponding eye; and even tumefaction and dis- 
coloration of the cheek and loose areolar tissue of the lower eyelid 



68 ELECTROCAUTERIZATION". 

may occur. It is generally best to allow about a week to intervene be- 
tween, cauterizations of the same side, but when patients from a 
distance can remain but a brief period the opposite turbinal can be 
burned in about four or five days after the first, if the operated areas 
are not too extensive. 

After each cauterization the operated surface should be covered 
with a coarse spray of a 10-per-cent. solution of camphor-menthol. 
Should any haemorrhage occur, the bleeding surface had best be 
treated with a 10-per-cent. solution of silver nitrate. If this remedy 
should not entirely stop the haemorrhage, a solution of the suprarenal 
gland must be employed. After such a management of cases that 
have been properly operated upon, there is generally little or no 
haemorrhage, pain, or reaction, but the parts pursue a placid course 
to recovery. 

The use of the cautery is really a simple operation, but care must 
be exercised not to approach too near the orifice of the Eustachian 
tube. We have seen acute suppurative inflammation of .the middle 
ear result from such procedures. Seiss, in speaking of such untoward 
sequels, cites cases of ear disease made worse by nasal treatment. The 
membrane being anaesthetized, a speculum is introduced and the light 
from the forehead-mirror is thrown into the nostril. The chosen 
electrode is introduced cold and placed on the benumbed area, when 
the current is turned on sufficiently to give a white glow. If the pa- 
tient evinces pain, or if the electrode is seen to burn as deeply as is 
desired, the current is interrupted and at the same instant the elec- 
trode is moved outward so as to part from the tissues before cooling. 
If the whole lower turbinal is hypertrophied, the anterior third is 
cauterized first, and at intervals of about a week the contraction and 
consequent opening will be sufficient to admit of treating the middle 
and posterior thirds. 

Unless the camphor-menthol treatment is used, swelling and 
sloughs occlude the passage until about the fourth or sixth day, when 
the sloughs separate. When the cauterization is extensive or deep, 
some considerable pain may be experienced for a number of hours, 
unless a pledget of cocainized cotton is left covering the surface. 
Occasionally a little pain is experienced in the upper incisors. If the 
septum is not hypertrophied the electrode should be kept away from 
it, and the burning is not carried deeply enough to include the peri- 
osteum. If suppuration is feared, glycozone may be substituted for 
I be camphor-menl hoi. 



SURGICAL TREATMENT FOR HYPERTROPHIC RHINITIS. 69 

Acute pharyngitis and ulcerative tonsillitis occasionally follow 
closely upon nasal cauterization, especially if the cauterization be 
quite extensive as to surface area or depth. The patient will be less 
likely to have pain, sneezing, and discharge from his nose after the 
operation if one or more coryza tablets be given. Although the 
writer has never seen grave consequences follow intranasal operations, 
it should not be forgotten that deaths have been attributed to them 
by Levy, Wagner, Quinlan, and others. Among the accidental effects 
reported are the following: Haemorrhage, amaurosis, various mani- 
festations of infection, meningitis, thrombosis of the longitudinal 
sinus, empyema of the maxillary antrum, hemorrhagic and purulent 
nephritis, purulent inflammation of the joints, and several less serious 
conditions. 

On the days following cauterizations the nose is sprayed with 
the antiseptic solutions already mentioned, and then by a 4-per-cent. 




Fig. 37.— Hobby's Steel Snare. 

solution of eucalyptol in lavolin, or the same strength of pine-needle 
oil, or benzoinol. 

For posterior hypertrophies Seiss prefers curettement. The snare 
(Fig. 37) is preferred by many specialists. It is introduced with 
the loop open, as shown in Fig. 36, and passed over the enlargement 
so as to engage it as near its base as possible, when, by drawing 
upon the wire or turning the wheel, the loop is made to sever the 
tissues. The Jarvis transfixing needle facilitates this manoeuvre. The 
needle is passed through the hypertrophy until it projects beyond; 
the snare-loop is passed over both ends of the needle so as to lie on 
its under surface and to cut between the needle and the base of the 
growth. The cutting is done by a turn of the wheel at a time, taking 
from one-half to one hour for the operation. The more time, the 
less haemorrhage. In removing posterior growths the rhinoscopic 
mirror is required, in order to view the field of operation (Fig. 8). 



70 



SURGICAL TREATMENT FOR HYPERTROPHIC RHINITIS. 



"When deformities of the cartilaginous septum necessitate their 
removal, this is best accomplished by means of a specially fashioned 
knife having a tapering, blunt point (Fig. 38). After anaesthetizing, 
the hypertrophy is severed by entering the blunt probe-point of the 
knife below and cutting upward. In this manner the occlusion of the 
field by haemorrhage is avoided if the cutting is done expeditiously. 

Exostoses are sawed off in a like manner (Fig. 41). The motion 
of the saw should be rapid, and one should not bear so hard upon 
the handle as to make the saw catch and stick. With practice one 



Fig.. 38.— The Author's Septum-knife. 

can work rapidly with this instrument. The electric drill is a very 
efficient instrument and is manipulated like a dentist's drill (Fig. 39). 
The electric trephines afford a very effective and rapid means of re- 
moving cartilaginous and osseous growths from the septum nasi. Fig. 
40 shows the exact size of two electric tubular saws, or trephines, the 
smaller of which is the one in common use in surgery of the nose and 
its connecting cavities. This instrument is capable of rendering ex- 
cellent service where little work is to be done: but it has several 




Tier. 39.— Electric Drills. 



serious faults which the writer has overcome in devising the larger 
trephine. 

In removing a large and long spur from the nasal septum it is 
necessary to trephine through the centre of the spur; then above and 
below the centre in lines parallel with the first section, if the small 
trephine is employed. If the spur is longer than the tube of the 
trephine, the instrument ceases to cut as soon as it penetrates the dis- 
tance of its own length, for the portion of the spur that enters the 
tube fails to pass out of the counter-opening as fast as it enters the 



SURGICAL TREATMENT FOR HYPERTROPHIC RHINITIS. 



71 



tube, and it prevents the saw from entering farther. This necessitates 
withdrawing the trephine, removing the cut portion of the spur, and 
readjusting the trephine for proceeding with the cutting. Meanwhile 
the field of operation is likely to become covered with blood, and more 
time is lost in removing this in order to see what tissues one is at- 
tacking. 



Fig. 40. — Electric Trephines. 

The large trephine has a counter-opening as capacious as can be 
made without sacrificing the strength of the tube, so as to allow the 
contents to pass out as fast as they enter. It is much longer than the 
average spur, so that it would operate more satisfactorily than the 
small trephine, generally, even if the counter-opening were smaller. 
Its generous diameter renders it necessary to drive the instrument 



r> 




Fig. 41. 



-The Author's Nasal Saws. 



through the tissues fewer times in order to remove a given amount of 
growth. 

In operating on the maxillary antrum the large trephine gives 
better results than the other. By passing the large instrument once 
into the antrum a canal of good size is obtained. Formerly I have 
passed the small one twice, and more times in some cases, before ob- 



72 THE X0SE AND THE FEMALE SEXUAL ORGANS. 

taining a sufficient opening for free drainage and efficient treatment. 
The large trephine is well adapted for opening the frontal sinus and 
the mastoid antrum. 

In order to reduce the haemorrhage to the minimum a saturated 
solution of suprarenal extract should be applied to the parts by means 
of cotton pledgets, and allowed to remain for ten minutes before 
using the cocaine. This contracts the blood-vessels and shrinks the 
tissues. Hence, less cocaine enters the circulation of the blood to 
produce toxaemia, the anaesthesia is more profound, and the bleeding 
is either prevented or greatly minimized. 

Dudley S. Keynolds prefers adrenalin chloride. He says: "It is 
a powerful haemostatic and acts promptly, generally within one minute 
from the time it is applied to mucous surfaces. Its effects persist 
from twenty minutes to four hours. It renders operations in the nasal 
passages and elsewhere nearly or quite bloodless, and does not predis- 
pose to secondary haemorrhage, but has the contrary effect." 

When the turbinate bone becomes enormously hypertrophied, 
turbinotomy is resorted to in order to remove the entire bone. This 
is accomplished with the saw or scissors (Fig. 45); but this operation 
is seldom necessary. William Scheppegrell and G-. Melville Black 
(The Laryngoscope, Xovember, 1897) have devised electromotor saws 
for operating in the nasal cavities. 

Hygienic measures and internal treatment must be employed 
according to the indications and on general principles, and the mat- 
ter of clothing is considered in the treatment of acute rhinitis. 



i & 



The Nose and the Female Sexual Organs. 

"A. Schiff has proved the observation of Fliess, that the pain of 
dysmenorrhcea was relieved promptly, in 34 out of 37 cases, by the 
a] >plication of a 20-per-cent. solution of cocaine to the 'genital spots' 
of the nose. Some cases he observed for months and he had over 200 
positive results. Hypogastric pain was relieved by cocainizing the 
turbinal, and sacral pain by application to the tuberculum septi. By 
first contracting the tissues with suprarenal solution a 3- to 5-per-cent. 
solution of cocaine was sufficient to stop the pelvic pain. Of 13 nega- 
tive cases, 4 had fixed retroflexion, 2 adnexal disease, and 1 had 
parametritis Two patients treated in Chrobak's clinic complained of 
hypogastric pain immediately upon application of the cocaine plug bo 
the corresponding turbinal. In IT cases the author cauterized the 
'genital spots' during the menstrual interval with trichloracetic acid 



ATROPHIC RHIXITIS. 73 

or electrolysis, with no return of the (fysmenorrhcea in 12 cases, 1 
being under observation from one and a half to two and a half years." 
("American Year-book," 1902.) 

Atrophic Ehixitis. 

Synonyms. — Ozsena; fetid catarrh; cirrhotic rhinitis. 

Pathology. — This form of nasal catarrh is a sequel of a pre- 
existing inflammation; indeed, it may be said to be the third stage 
of rhinitis in the logical order in which we have treated of the sub- 
ject: (1) simple rhinitis, (2) hypertrophic rhinitis, and (3) atrophic 
rhinitis. In the latter variety there occurs an absorption and con- 
traction of the newly formed connective tissue, obliteration of the 
venous sinuses, and atrophy of the mucous membrane. The turbinate 
bodies are reduced by this sclerotic process to less than their normal 
calibre, and the nasal cavities are correspondingly increased in size. 
The mucous glands participate in the general cirrhotic condition and 
exude less than the normal amount of secretion, which leaves the 
membrane dry; or the mucus becomes dried into scales or crusts, 
which ferment or decompose and emit a foul odor. The latter condi- 
tion, ozaena, is not always present, and is probably dependent upon 
a strumous diathesis. 

Etiology. — The real cause of atrophic rhinitis is veiled in ob- 
scurity. Although it undoubtedly follows a catarrhal condition of the 
mucous membrane involved, there are cases in which the disease ap- 
pears to be one of an atrophic nature from the beginning. It is not 
rarely that we see it following hypertrophic rhinitis and even asso- 
ciated with it in the opposite nostril, and occasionally in the same 
side of the nose. 

Loewenberg discovered in the crusts of ozama a pathogenic cocco- 
bacillus and large bacilli in short chains, or in masses, appearing as 
diplococci. Hajek found a bacillus that he believed to be the cause 
of the odor and named it the "bacillus fcetidus ozamse." While it is 
not likely that these bacilli give rise to the disease itself, they prob- 
ably are the cause of the bad odor. The bacilli are not found in the 
mucous membrane, but in the secretions that form the decomposing 
crusts. Abel and Baurowicz also have found the Loewenberg ba- 
cillus. 

Symptomatology. — In most cases of atrophic rhinitis the nasal 
membrane is of a very pale color and is dry in appearance. The lumen 



74 ATROPHIC RHINITIS. 

of the passages is enormously increased, so that one can see through 
to the throat and even to the orifices of the Eustachian tubes in rare 
cases. One or more of the turbinals may remain somewhat hyper- 
trophied, indicating the previous condition, while the others are 
shrunken into miniatures of the normal bodies. On account of the 
enlargement of the cavities the patient is unable to bring sufficient 
air-pressure to bear to dislodge the drying secretions, and they are 
permitted to stick fast until decomposition renders them fetid and 
indescribably odoriferous. In this form, or ozaana, smell is lost — a 
beneficent provision — and taste is impaired, and sometimes the hearing 
also. A muco-purulent discharge is often found in such cases, and 
this, drying into crusts, presents a green or dark-brown color. 

Diagnosis. — This is not difficult, for the appearance of the parts 
in the simple atrophy, and a smell of the sickening, disgusting fetor 
of ozsena are distinctly characteristic. Suppuration of the accessory 
cavities is generally unilateral. In syphilis necrotic bone may be de- 
tached with the probe, or the bridge may become depressed and the 
septum eroded away. 

Prognosis. — As this disease is usually found between puberty 
and the thirty-fifth year, it may be expected to disappear in time of 
itself; but its disgusting character in about 50 per cent, of the cases, 
as much as its possible deleterious effect on the patient's general 
health, calls for persistent treatment. This must be measured by 
months, and it may take a year or more to eradicate the ozama; but 
this can be done. 

Treatment. — In the simple, dry, non-odorous atrophy stimulating 
applications, like a 4-per-cent. solution of iodine in benzoinol, 
fumes of resublimed iodine crystals from the inflator (Fig. 134), and 
gentle massage of the parts with the smooth probe will increase the 
circulation and nutrition. Vibratory massage is practiced as follows: 
After softening the crusts by the various sprays cotton is twisted 
thickly on the long applicator and carried to the site of each crust. 
Sufficient friction is then employed to dislodge and remove the scabs. 
Fresh cotton swabs are carried into the nasal cavities and used in this 
way until the mucous membrane is entirely cleaned and free from 
discharges. Then these cotton balls are used to gently beat and 
stroke the tissues, with care not to denude the membrane of its epi- 
thelium. To avoid the latter it is well to anoint the cotton with some 
stimulating oil, like benzoinol. The massage is practiced for about 
five minutes at a time over all the atrophic tissues. The membrane 



ATROPHIC RHINITIS. 75 

is thus cleansed and sufficiently irritated to increase the circulation 
of blood and to stimulate the mucous glands to secretion. The stimu- 
lating effect of the massage can be augmented by following it with 
the application of iodine fumes or thymol, 3 grains to the ounce of oil. 

When ulcerations of the nasal septum occur, C. C. Eice treats 
them by means of friction with cotton moistened with listerin, rubbing 
several ulcerations rather forcibly and for a few seconds at a time. C. 
H. Knight prefers menthol to any other local remedy, but recommends 
borolyptol and ichthyol also. (The Laryngoscope, May, 1900.) 

Dionisio, Braun, Chiari, and Laker (Journal of Laryngology, 
1894) advocate intranasal vibratory massage by stroking and vibra- 
tion with hand or electric cotton-covered probes. 

For the ozsena hydrozone and washes of an alkaline, antiseptic 
character must be copiously used to free the cavities of all decom- 
posing masses. The nasal douche so often advised is mentioned only 
to be condemned, on account of the liability of damaging the Eusta- 
chian tubes and ears and even the cavities accessory to the nose. 
Seller's solution is excellent, and should be thrown in a coarse spray 
until the crusts are loosened and expelled, leaving a free, clean mem- 
brane to receive the curative medicaments. Listerin, pasteurin, gly- 
cothymolin, and micrazotol are good detergents. The latter contains 
boroglyceride, eucalyptol, thymol, resorcin, menthol, and benzoic acid. 

The patient should be given the wash to use morning and night, 
after which he should spray the nostrils and throat thoroughly with 
a 3-per-cent. solution of camphor-menthol in lavolin. Two or three 
times a week the surgeon, after cleansing the cavities, should spray 
them with such remedies as carbolic acid and iodine in benzoinol (4 
per cent.), and then dust the membrane all over with aristol powder 
(Fig. 144). When the odor is very foul the powder application should 
be preceded by a spray of a 10-per-cent. solution of camphor-menthol 
in lavolin. 

John North informs me that he obtains the most satisfactory 
results from touching the atrophic area, after removing the crusts, 
with a solution of permanganate of potassium, 30 grains to the ounce 
of water. In a few weeks the scabs disappear and cease to form. 

Tonic and alterative constitutional treatment and hygienic meas- 
ures must be resorted to on general principles. 



CHAPTER VI. 
DISEASES OF THE NASAL CAVITIES (Continued). 

Epistaxis. 

Synonyms. — Xose-bleeding; nasal haemorrhage; haemorrhagia 
narium. 

General Considerations. — Bleeding from the nose may have its 
origin in the nasal cavities proper or in the adjoining sinuses. It is 
frequent in childhood, occasional in old age, and rare in middle life. 

Pathology. — The bleeding-point is most often found on the side 
of the septum, near the floor, and adjacent to the opening of the nose. 
Vessels may, however, rupture in any part of the membrane, or the 
haemorrhage may proceed from one of the accessory cavities. Prob- 
ably the bleeding occurs most frequently from ulceration of the mem- 
brane, by means of which the blood-vessels are penetrated by an ex- 
tension of the erosion to their walls. This process perforates the sep- 
tum; crusts form on the ulcerating parts, and upon their removal 
a raw, bleeding surface remains. 

Etiology. — Falls and blows, the bad habit of picking the nose, 
foreign bodies, fractures, vicarious haemorrhage, purpura hemor- 
rhagica, etc., cause nasal haemorrhages. 

Symptomatology. — Bleeding may come on without any premoni- 
tory symptoms, and even during sleep. The blood usually trickles 
from one nostril, a drop at a time, but sometimes runs in a stream. 
Only a slight amount is lost ordinarily, but it may amount to an 
alarming quantity and may even prove fatal. Frequent haemorrhages 
tend to produce anaemia and demand corrective measures. 

Diagnosis. — The condition is usually made out without difficulty. 

Prognosis. — This is ordinarily good, but in old age it may be 
indicative of degeneration of the walls of the blood-vessels. In low 
fevers and diphtheria it is an ominous symptom. 

Treatment. — The most common means adopted to check bleed- 
ing from the nose is to keep the head upright and compress the nos- 
trils with the thumb and forefinger, or apply cold to the nose or the 
back of the head and spine. Hot water is recommended by some to 
(76) 



NASAL HEMORRHAGE. 77 

be applied to the nose or injected into the bleeding nostril. The 
icebag (Fig. 194) is a convenient means of using continuous cold. 
Pulverized alum and tannin are useful. The latter is used in powder 
or, as mentioned later, in connection with tampons. A 10-per-cent. 
solution of cocaine on a cotton pledget packed firmly between the 
bleeding-point and the opposite wall is effective. 

It is sometimes difficult, even with good reflected light, to locate 
the source of haemorrhage, but this should be accomplished if pos- 
sible. Antipyrin in 3-per-cent. watery solution or in powder and the 
liquor ferri perchloridi are useful. Some writers speak highly of the 
electrocautery, but the author cannot indorse it for this purpose. 

Suprarenal extract, in a fresh saturated solution, is the most 
effective astringent we possess. Pledgets of cotton or gauze should be 
saturated with it and packed against the bleeding surface and allowed 
to remain for twenty-four hours. At the expiration of this time it 




Fig. 42. — Bellocq's Cannula Introduced. 

must be removed, otherwise it will decompose and emit a very foul 
odor. 

"Lewis A. Somers, to control persistent bleeding from the septum, 
had adrenal solution applied over the bleeding area at infrequent 
intervals for several weeks. The patient had had almost daily or 
nightly epistaxis for several months. There was intense congestion 
of the right side of the septum, with enlarged vessels, though they did 
not appear angiomatous nor was there a history of haemophilia. The 
septum became pale and the vessels contracted to their normal size 
after the treatment, and the bleeding has not recurred." ("American 
Year-book," 1902.) 

If the simpler measures fail, resort must be had to tampons. 
The following method is most efficacious: A long strip of lint, linen, 
or cotton cloth, three-eighths of an inch (one centimetre) wide, is 
immersed in a saturated solution of tannic acid in water, and then 
the water is pressed out, leaving the cloth thoroughly medicated. 
One end of this is carried by the delicate angular forceps or probe as 



78 NASAL HEMORRHAGE. 

far into the nose as the case requires. Then the remainder of the 
tampon is packed in, a small loop at a time, until it is pressed firmly 
into all the sinuosities, and the cavity is completely filled. Any sur- 
plus of the strip is then cut off. 

Should tamponing of the anterior naris fail, posterior plugging 
must be added to it. In this case the posterior nares must be plugged 
first, as follows: Bellocq's cannula (Fig. -±2) is threaded through the 
eye in the end of the spring with a strong string. The thumb-screw 
is adjusted so that it will throw the spring out after its introduction, 
as shown in the cut. Then the sound is introduced like the Eusta- 
chian catheter until the distal extremity projects downward over the 
velum palati. At this moment the spring is extruded until it, with 
the string, is seen through the open mouth. With hook or forceps 
one end of the string is brought out of the mouth and a pledget of 




Fig. 43. — Curette-forceps. 



cotton or lint as large as an adult's thumb is tied firmly to it. This 
is drawn backward and upward through the mouth and throat into 
the posterior nares. It should be made to plug effectually both pos- 
terior nares, for otherwise haemorrhage might continue through the 
free one. In passing the tampon behind the palate, the finger should 
be introduced to prevent drawing the palate upward with the cotton. 
Then the finger can pack the tampon well into the nares. The string 
protruding- from the anterior naris is fastened back of the ear with 
adhesive plaster. In hot weather this must be watched, or the per- 
spiration will loosen it and allow the tampon to become displaced or 
swallowed. After a day or two the packing must be removed to pre- 
vent septicaemia. In the absence of Bellocq's cannula the Eustachian 
catheter can be substituted, and the writer has succeeded with a silver 
male catheter in an emergency. 

Constitutional treatment may be required, — iron, ergot, etc. 



nasal polypi. 79 

Nasal Polypi. 

There are three varieties of benign neoplasms to which the term 
"nasal polypi" is applied: mucous, fibrous, and cystic. 

MUCOUS POLYPI. 

These occur in multiple form, and sometimes they are very nu- 
merous (Plate II). They are a pale-pink or ashy-gray color, and are 
most troublesome in damp weather, when they absorb moisture, caus- 
ing them to swell and occupy increased space. They are usually 
found in middle life, from 20 to 40 years, and occasion stenosis of 
the nares and mouth-breathing (Fig. 71). The mucoid variety is 
the most common. Patients often observe movements in these polypi, 
which are occasioned by forcible currents of air in sniffing or blowing 
the nose. 




Fig. 44. — Very Strong Cutting Forceps. 

They are generally attached either to the middle turbinal or to 
.the outer wall of the middle meatus. (See "Treatment," below.) 

FIBEOUS POLYPI. 

This variety presents a single, dense, resisting surface to the 
probe. It may develop into so large a mass as to invade the naso- 
pharynx (Plate IV) or project from the nostril. It causes stenosis 
and supra-orbital headache, and its expansion causes pressure and 
deflection of the septum, as well as absorption of the turbinals. Ne- 
crosis of the bones and invasion of the adjacent sinuses may occur. 
The nose in some cases is bulged outward at the sides, which gives 
the arch a flattened appearance. (See "Treatment," below.) 

CYSTIC POLYPI. 

These are very rare, and consist of a cyst or sac filled with a 
yellowish or bloody, serous fluid. 



80 TUMORS OF THE NOSE. 

TREATMENT. 

Polypi should be removed preferably with the cold-wire snare 
(Fig. 37). The loop of the snare is introduced expanded, as seen in 
the electric snare (Fig. 36), and made to embrace the pear-like tumor 
and to slide up to its attachment. The polypus is then slowly cut off 
and the point of attachment is cauterized with the electrocautery or 
chromic acid to prevent a return of the growth. This is preferable to 
removal with the forceps or scissors, and if the evulsion is not too 
rapidly accomplished little haemorrhage ensues. The biting curette- 
forceps (Figs. 43 and 44) are especially serviceable for searching out 
and removing the mere buds of polypi in the upper nasal passages. 
The writer often severs these growths with the electrocautery, which 
sears the seat of attachment and renders the operation bloodless. 
After-treatment is the same as after removal of hypertrophies, already 
given. 




Fig. 45. — Casselberry's Saw-tooth Scissors. 

Papillomata. 

These are benign neoplasms of infrequent occurrence. They 
may be single or multiple, and are most often attached to the lower 
part of the septum or inferior turbinal. (See "Treatment" under 
"Erectile Tumors/ 7 ) 

Erectile Tumors. 

These are very rare. They have the appearance of an hyper- 
trophy of the turbinate body, except that pulsation can be detected 
in them. This is in consequence of their close relationship to an 
artery, and their removal is likely to be attended with considerable 
haemorrhage. 

Treatment consists in removal of the growths either by chemical 
or mechanical means. Chromic acid or the galvanocautery may suf- 
fice, or the nasal scissors (Fig. 45) may prove preferable. 



new growths op the nose. 81 

Chondromata. 

Cartilaginous tumors are rare growths occurring about the age 
of puberty and springing from the septal cartilage. Their location, 
unyielding firmness, and sessile shape distinguish them from fibro- 
mata. The color is a light pink, and they have not the smooth sur- 
face of fibrous tumors, but are indented by numerous depressions. 

Treatment. — If these growths prove troublesome they should be 
removed. Many methods are in use, — the knife, saw, chisels, punch, 
dental or electric drills and trephines, the electrocautery, etc. 

The cartilaginous growth is easily removed, under cocaine or 
eucaine, by the author's septum-knife (Fig. 38). The cutting should 
be done as already described, and care should be taken not to per- 
forate the septum. It is claimed by some rhinologists that healing 
does not take place so readily after the electrocautery as after cutting, 
but the author has not been able to confirm this opinion. 

OSTEOMATA. 

The bony tumors also are very rare. They are offshoots from 
the mucous membrane and the product of an osseous degeneration of 
connective tissue. Their pressure produces headache, asthenopia, 
occasional haemorrhages, and ulceration with a purulent discharge. 
Unlike rhinoliths, they resist a needle and do not crumble. (See 
"Treatment" under "Exostoses/') 

Exostoses. 

Osseous growths are frequently met with in the nose. They usu- 
ally take the form of ridges or spurs upon the bony septum, encroach- 
ing upon the lumen of the passage sometimes to a considerable ex- 
tent. Occasionally the growth attains to very large proportions 
until pressure is produced on the opposite turbinal or adhesion to it 
occurs, forming a synechia or bridge across the canal. Figs. 25, 
26, and 57 show such conditions. In Fig. 25 the probe is inserted 
to the point of adhesion between the exostosis and the inferior turbi- 
nate bone. The contour of the latter will be seen in Fig. 26 to have 
been altered by the pressure, from a convexity, like the opposite one, 
to a concavity. The septum is deflected toward the exostosis. 

These growths arise from the periosteum and may occasion no 
inconvenience if no pressure is exerted on surrounding tissues, but 



82 RHINOLITHS. 

when they impinge on the posterior portion of the inferior turbinal, 
reflex asthma may result. They are hard, immovable, light pink, and 
bleed easily on pressure with the probe (Plate III). They may cause 
headache, amblyopia, and other ocular disturbances. 

Treatment. — Osteomata and exostoses should be removed when 
they have attained to such a size as to occasion symptoms of their 
presence. The former may be removed by the snare, strong saw- 
tooth scissors, curette, or forceps; the latter by the saw (Fig. 41). A 
strong solution of cocaine must be used, preferably 20 per cent. The 
electric trephine and drills are convenient for this purpose, and the 
dental motor also is effective. The writer generally employs the elec- 
tric trephines and drills of various sizes (see Figs. 39 and 40). 

Rhinoliths. 

Synonyms. — jNTasal calculi; calcareous concretions. 

Pathology. — Ehinoliths consist of the salts of the nasal secretions 
deposited on some nucleus, such as a foreign body, necrosed bone, or 
a blood-clot. They are composed of calcium phosphate and carbonate, 
magnesium phosphate, sodium chloride, and small quantities of or- 
ganic matter, such as mucin and proteid material. They vary in color, 
form, and size. Usually they are gray or brown. The rhinolith shown 
in Fig. 46 is greenish brown. The third and fourth large pieces in 
the top row are shaped like coral, although the perspective was not 
right to illustrate this feature in the central one. The photo-engrav- 
ing shows the exact sizes of the fragments, all of which before removal 
constituted one rhinolith, the weight of which was seventy-one grains. 

Symptomatology. — A rhinolith is, in effect, a foreign body and 
gives rise to both subjective and objective symptoms. Among the 
former are nasal irritation, headache, obstruction, and defective and 
perverted sense of smell. The objective symptoms are a serous, 
mucous, purulent, or bloody discharge from the nose, with a disa- 
greeable odor in some cases, and impaired resonance of the voice. 
The septum has been found deflected sufficiently to hide the stone in 
several instances. 

Diagnosis. — To illustrate the ease with which a rhinolith may be 
overlooked it is only necessary to mention that a number of physicians 
had examined the nasal cavity containing the large calculus shown in 
the accompanying figure without delecting its presence 1 . As soon as 
the probe came in contact with it, the hard, gritty, characteristic 
sensation imparted by the stone was readily apparent. It was slightly 



RHIXOLITHS. 



83 



movable, but its removal without being crushed was out of the ques- 
tion. The secretions so effectually disguise the nature of the obstruc- 
tion that the careful use of the probe is necessary to a correct diagnosis. 
This calculus was located nearer the posterior than the anterior 
naris. 

Prognosis. — Extraction of the stone and proper after-treatment 
insure a cure. Although the one shown in the engraving was removed 
in May, 1899, there has been no recurrence, and no trouble in that 
nasal fossa since. 

Treatment. — Being substantially a foreign body, a rhinolith 
should be treated as such. If it is small enough to glide easily out of 
the nostril it can be extracted with forceps, a lever, or a bent probe. 
Cotton firmly twisted on a holder may be made to engage the prongs 




X hinollt^s 



Fig. 46. — Fragments of a Rhinolith, Exact Size, Weighing Seventy-one 
Grains, from a Woman Fifty-nine Years Old. (Author's Case.) 

of the stone in its fibres, when traction may withdraw the calculus 
from its nest. The large one illustrated herewith required to be 
crushed before its removal by the natural channel was possible. It 
was found on the floor of the right nasal fossa of a woman 59 years 
old, who suffered from chronic rhinitis, and chronic non-suppurative 
inflammation of the middle ears, accompanied with intolerable itching 
in the auditory canals, and attacks of intense hyperemia and heat of 
the left external auditory meatus and auricle. 

Before attempting the extraction of these concretions the fossa 
should be cleansed, disinfected, treated to suprarenal extract to con- 
tract the tissues, and cocainized. The very large stones will demand 
powerful crushing forceps. Great care should be used to avoid injury 
to the mucosa and submucous tissues during the operation. 



84 



NEW GROWTHS OF THE NOSE. 



Sarcomata of the Xose. 

These are, fortunately, rare occurrences. Sarcoma and carcinoma 
are sometimes developed in this region. Sarcoma does not differ in 
this locality from its characteristics in other situations. It is more 
likely to be found on the septum, but may invade the other nasal 
walls. It gives rise to pain, obstruction of respiration, fetid dis- 
charge, and possibly difficulty in swallowing and impaired hearing 
when it extends to the naso-pharynx. If it invade the nasal vault the 
cranial cavity may become involved, resulting in a fatal termination. 




Fig. 47.— Destruction of the Hard Palate, the Soft Palate Remaining 
Unharmed. Through the very spacious perforation in the hard palate is 
seen a dark object with round and roughened surface: 1, a myaloid sar- 
coma. 



Sarcomata are of rapid growth, and present a dark, roughened 
surface in some instances; in others they are pale. Fig. 47 shows 
a myaloid sarcoma springing from the inferior turbinated body of a 
syphilitic. I am indebted to the courtesy of E. Pynehon for a photo- 
graph of this case. As pressure develops laterally, bulging of the 
nasal walls becomes apparent in the contour of the nose and the 
prominence of the eyes. The gravity of the disease is manifested in 



NEW GROWTHS OF THE NOSE. 85 

a general constitutional disturbance. The probe causes bleeding and 
discovers a soft, fleshy mass. This is a rapidly fatal disease of less than 
a year's duration. 

Treatment. — Complete extirpation is the only remedy. Ano- 
dyne and astringent applications after the disinfecting and cleansing 
washes are only palliatives. 

Carcinoma. 

Cancer of the nasal passages differs in no way from the same dis- 
ease elsewhere. An ulcerating surface with a brown, serous fluid, pain 
and haemorrhage, infiltration of the cervical glands, and constitutional 
symptoms characterize this disease. The end is death. 

Treatment. — There is no certain curative treatment. The growth 
may be somewhat retarded and the suffering ameliorated by anodyne 
and astringent applications. Cocaine and aristol are the best. Hasse 
and others report good results from interstitial injections of alcohol. 
Those are treated of under the heading of "Treatment" in "Carci- 
noma of the Pharynx." 

The x-ray is claimed to exert a curative influence on cancer and 
lupus, but sufficient data upon which to base a positive opinion have 
not yet been obtainable. 



CHAPTER VII. 
DISEASES OF THE NASAL CAVITIES (Concluded). 

Tuberculosis of the Xose. 

Fortunately this is a rare affection. It appears in two dif- 
ferent forms: an ulceration and a neoplasm, or tumor. The ulcer 
appears on the septum near the orifice of the nostril, and may extend 
from this point to other parts of the nose and it may even invade 
the upper lip. It is more likely to be secondary to tuberculous affec- 
tions of other organs than a primary manifestation. The ulcer ap- 
pears as a yellow or gray surface with a round, elevated, uneven 
border. There is a purulent discharge, more or less tinged with blood, 
and of a disagreeable odor. There is no tendency toward cicatrization, 
and after being once healed it has a strong disposition to break out 
again. Pain is not a common symptom. Sooner or later the disease, 
which is now generally conceded to be due to the bacillus tubercu- 
losis, invades the larynx and lungs and terminates in death. 

In eight cases of tubercular tumors of the nose seen by Shaffer, 
all were located on the cartilaginous portion of the septum. These 
granular neoplasms presented as nodules, some of them attaining 
to the size of walnuts, and were pale pink or red. After the removal 
of these soft masses the perichondrium was found to be involved, and 
became ulcerated, with the result of causing perforations of the 
septum. It may not be possible to find tubercle bacilli, or only a few 
may be detected. 

The writer has observed cases exhibiting the typical symptoms, 
and pursuing the well-known course, of tuberculosis even unto death, 
in which the many examinations of various bacteriologists utterly 
failed to discover a tubercle bacillus. 

Tubercular ulcers are more likely to appear on the cartilaginous 
section of the septum than on the osseous segment, but they have 
occurred on the turbinals. 

Treatment. — Cleansing, antiseptic solutions, such as are noted in 
Chapter I, must be freely used. Curettement, the electrocautery, 
chromic or lactic acid, — the latter in 50-per-cent. strength, — may be 
(86) 



SYPHILIS OF THE NOSE. 



87 



resorted to for the removal of the caseous, tuberculous material that 
forms the base of the ulcer. In case of a tumor, it should be removed 
with the snare and the attachment-surface should be cauterized. 
Astringents and iodoform are useful in retarding disintegration and 
the invasion of adjacent structures. If pain is present, morphine, 
cocaine, or eucaine may afford temporary relief. Codliver-oil should 
be given, and guaiacol in doses of 1 to 10 minims after each meal. 
This is best administered in glycerin, milk-broths, or wine. Creasote 
is often useful. For other remedies consult the sections on "Tuber- 
culosis of the Pharynx" and "Tuberculosis of the Larynx." 




Fig. 48. — Destruction of the Bones Forming and Supporting the Bridge 

of the Nose. 



Syphilis of the Nose. 

The manifestations of syphilis in the nose correspond to the 
three stages of syphilis occurring in other organs. It may be heredi- 
tary or acquired. In the former it appears either before the third 
month of childlife or between the third year and the beginning of 
adolescence. In infants the affection simulates coryza, but tends 
strongly toward suppuration. The discharge is more acrid and irri- 
tating than that of simple rhinitis, and produces a red and raw ap- 
pearance of the upper lip. The borders of the nostrils are cracked 
and chapped. Nasal respiration is embarrassed, and, in consequence 



88 



SYPHILIS OF THE NOSE. 



of the interference with sucking, the babe is ill nourished and puny. 
If the disease attack the cartilage or bone, an offensive odor is im- 
parted to the discharge. 

The later form of hereditary syphilis presents manifestations of 
the tertiary form. It attacks the cartilaginous and osseous septum 
and then the turbinate bodies, and by carious and necrotic processes 
they undergo more or less complete destruction. The supports to 
the end and bridge of the nose disappear and the end may drop down 
toward the upper lip, or, if it remain supported by a remnant of the 




Fig. 49. — Partial Destruction of the Bones of the Nose, Resulting in 
Two Perforations: One in the Centre of the Bridge and Another at the 
Inner Angle of the Right Eye. (From the Author's Clinic.) 



cartilaginous septum, the centre of the bridge may cave in and pro- 
duce the exaggerated pug-nose deformity (Figs. 48 and 49). 

Diagnosis. — With care one will be able to distinguish the obsti- 
nate, persistent, pus-producing rhinitis of a syphilitic infant from an 
ordinary cold in the head which in an uninfected child tends toward 
speedy resolution. Mucous patches may be discernible in the nares 
and a papular eruption on the skin. These children are often badly 
nourished, old looking, and unpromising. After taking into account 
all the characteristics mentioned, if in the later form there exist any 



SYPHILIS OF THE NOSE. 89 

doubt as to the nature of the disease, a course of antisyphilitic treat- 
ment will dispel the uncertainty. 

Prognosis. — If the pathological process has not involved the 
cartilaginous or bony walls, and if the patient is not greatly debili- 
tated, the chances of recovery are good. 

Treatment. — Cleanliness and specific medication are often re- 
warded by brilliant results. The antiseptic sprays given in Chapter 
I are indicated, after which tincture of iodine applied to the ulcerating 
surfaces will be followed by healthy granulations and cicatrization. 
If the ulcers do not cicatrize promptly, it is advantageous to dust the 
parts with aristol or nosophen (Fig. 144) after the cleansing process. 
We generally use the mixed treatment, — small doses of mercury with 
potassium iodide. The latter may have to be given in increasing doses 
until the system is saturated. This treatment, vigorously pursued 
and carefully watched, gives gratifying results. 




Fig. 50. — The Author's Nasal Supporter. 

In great debility and malnutrition codliver-oil, malt, tonics, and 
improved sanitary surroundings may be necessary. When extensive 
deformity of the nose takes place, it may become necessary to resort 
to a rhinoplastic operation to restore the contour and continuity of 
the organ. When the cartilaginous support of the end of the nose 
has been destroyed so as to let the tip fall upon the upper lip, the 
author has restored the natural lines by a device shown in 'Fig. 50, 
which he has named a "nasal supporter." It is fashioned to fit into 
the tip of the nose, so that the sides or wings of the supporter will 
correspond to the alas nasi. It is so placed as not to be visible when 
in position. They were first constructed of aluminium, but the bright, 
reflecting surface was observable. Later I experimented with vulcan- 
ized rubber, and found that, after making the surface a dull black, 
it answered all requirements. The improvement in the facial appear- 
ance after restoring the pendulous nose to its normal position is some- 
thing to be appreciated. 



90 GLANDERS. 

Destruction of the major portion of the septum nasi does not 
necessarily result in external deformity. The writer has under ob- 
servation such cases in which there is no external discoverable evidence 
of the internal architectural desolation. 

Lttpus of the Nose. 

Lupus affecting the nasal cavities is a rare affection except as 
an extension of primary lupus of the face or pharynx. The nodules — 
which are found more abundantly on the septum than on the turbi- 
nals — break down, ulcerate, and discharge a foul-smelling, purulent 
secretion. In and about the prominent border of the ulcer can be 
seen the hard, but resilient, tumefactions, or nodules. As the dis- 
charges dry upon the ulcers, brown or greenish crusts form, offering 
more or less obstruction to the nasal respiration. Pain, radiating to 
the surrounding structures, is complained of, and the ulcer is sensi- 
tive to touch. This is easily differentiated from ozaena. 

Treatment. — In addition to the detergent and antiseptic sprays 
mentioned in treating of ozsena, etc., the treatment is the same as 
that given for lupus of the ear. 

Glanders. 

Glanders is a disease derived from the horse and is encountered 
among horse-farriers, coachmen, etc. It is due to a specific contagion 
and manifests its presence by the formation of pustules which give 
way to ulcers of the skin. It attacks the nose and throat, from which 
a bloody pus is discharged in large quantities. Constitutional symp- 
toms characteristic of a serious systemic invasion or toxaemia indicate 
the gravity of the disease. When the infection extends to the lym- 
phatic glands and skin in various parts of the body it is termed 
"farcy/ 5 

This disease is either acute or chronic. The acute form is ush- 
ered in by symptoms similar to those of the eruptive fevers: chills, 
nausea, vomiting, fever, and red rash on the nose and face resembling 
erysipelas. This is followed by the appearance of blisters, which 
burst and leave their contents on the skin to dry into crusts. On 
removing these an ulcerating surface is disclosed that shows no in- 
clination to heal, but rather to extend over the surrounding parts. 
The pustular eruption invades the nose and throat, causing embar- 
rassment of respiration. The copious, tenacious discharges from the 



FURUNCULOSIS OF THE NOSE. 91 

nose and throat, and sometimes from the eyes, keep the patient oc- 
cupied freeing the passages. In the chronic variety the secretion is 
not so copious, and it may be lacking, except in the desiccated form of 
scabs on the nasal and pharyngeal membrane. 

Symptoms suggestive of tuberculosis come on later: colliquative 
diarrhoea and sweats, huskiness of the voice, and difficulty of degluti- 
tion and respiration from tumefaction of the mucous membrane of 
the pharynx and about the glottis. Great prostration and delirium 
precede death. 

The diagnosis may be obscured by the many symptoms that are 
characteristic of other affections,, such as typhoid fever, rheumatism, 
syphilis, pysemia, etc., but the history of the patient, exposure to in- 
fection from horses, and lack of further pathognomonic symptoms of 
other diseases must be considered. As distinguished from typhoid, 
we have the pronounced nose, throat, and skin eruptions and dis- 
charges and ulcerations; from articular rheumatism, pains in the 
muscles and tenderness surrounding the joints; from syphilis, the 
constitutional disturbance and absence of proving by specific reme- 
dies; from pyaemia, even when abscesses are found there is little or 
no chilliness. 

The acute form is rapidly fatal, lasting only about a week, while 
the chronic variety may persist for several months or a year. About 
half of all the cases die. 

Treatment. — No antitoxin has yet been evolved that acts as a 
specific for this disease. From the nature of the case it is to be ex- 
pected that such a remedy will yet be found. No treatment so far 
tried has a decided influence in curing or retarding the progress of 
this virulent affection. It must be left to the practitioner to meet 
symptoms and indications as they arise and appeal to his knowledge 
of the general principles of medicine. 

FURUNCTJLOSIS OF THE NOSE. 

Boils in the nose are a common source of discomfort. They occur 
repeatedly in some individuals and cause soreness, redness, and swell- 
ing of the end of the nose, lasting about a week. Small furuncles 
often develop just within the opening of the nostril, especially on the 
upper border, and originate in a hair-follicle. They render blowing 
and wiping of the nose very painful. 

Treatment consists in local and constitutional remedies. To the 
boil situated within the border of the naris a pledget of cotton may 



92 LOSS OF THE SENSE OF SMELL. 

be applied after moistening it with a 10-per-cent. solution of cam- 
phor-menthol in lavolin or benzoinol, or a 12-per-cent. solution of 
carbolic acid in glycerin may be substituted, as recommended in the 
treatment of furuncle of the ear. When pus is found it is evacuated, 
giving an opportunity for the remedies to enter the cavity. This 
treatment should be followed by the application of the yellow-oxide- 
of-mercury ointment, 5 grains to the ounce in vaselin, or the car- 
bolic-acid ointment. Sulphide of calcium has a reputation of repress- 
ing or preventing pus formation, and can be given in those cases in 
which recurring crops of furuncles torment the patient. The author 
has used with satisfactory results arsenious acid in doses of Vso grain 
three times a day, increasing gradually to two or three times that 
quantity for a short time, until the patient was free from these symp- 
toms, and, if they reappeared after a few months, repeating the treat- 
ment with larger doses continued for a longer time. This treatment 
has been successful in breaking up what appeared to be an established 
habit of body in which furuncles broke out with every spring opening. 

Anosmia. 

Absence or loss of the sense of smell may be due to central lesion 
or peripheral diseases. Affections of the Schneiderian membrane may 
destroy the nerve-termini or offer such obstructions as to render them 
inaccessible to odors. Acute inflammation of this membrane and 
suppuration of the adjacent cavities, such as the frontal sinuses, that 
cause the membrane to become bathed in purulent discharges, and 
syphilis and atrophic rhinitis, czasna, etc., — that produce destruction 
of the membrane, — cause, on the one hand, temporary impairment 
or absence of the function of the olfactory nerve, and, on the other, 
irreparable loss of smell. 

Blows in the region of the olfactory bulb, and occasionally in 
other parts of the skull, cause injuries to the bulb from which it does 
not recover. Excessive tobacco-smoking, snuff-taking, and opium- 
using either blunt or obliterate the sensibilities of the olfactory nerve. 
The sense of taste generally suffers more or less in all these instances. 

Treatment. — Anosmia due to acute inflammation of the nasal 
and connecting cavities generally disappears when the cause of it is 
removed. The appropriate treatment then is the same as for the 
inflammation that produces it. When the loss of smell has existed 
for several years the outlook for its restoration is not encouraging. 



DEFORMITIES AND DISEASES OF THE NASAL SEPTUM. 93 

Yet the writer has seen a partial return after the whole mucous lining 
of the nasal cavities had gone through a protracted siege of ulcera- 
tion in consequence of an irregular physician spraying the cavities 
with a corroding fluid hy mistake, resulting in a complete loss of the 
sense. To complicate the case there was syphilitic infection. In such 
cases the treatment detailed for syphilis of the nose and ozaena is ap- 
propriate. Absolute cleanliness and nerve-tonics, such as strychnia 
and the faradic current, are indicated. The negative electrode is 
placed over the root of the nose and the positive on the occiput, both 
electrodes being saturated with salt water. 

Parosmia. 

In parosmia the sense of olfaction is perverted. This happens 
even where the sense is normal for all objective odors. Various sub- 
jective odors are complained of, all disagreeable, such as oils, carrion, 
kerosene, etc. A physician under my care was annoyed by a constant 
subjective odor of "greasy rags or soap-grease." This symptom may 
be due to disease of the nasal mucous membrane, the decomposition 
of retained nasal secretions, disease of the olfactory nerve, or cerebral 
lesion and overstimulation of the nerve. As an example of the latter 
cause: I have treated a gentleman who for many years has been en- 
gaged in the perfume business, and during that time has gradually 
lost his sense of smell without any apparent causative lesion in the 
nasal cavities. Perverted olfactory function has been observed in the 
insane and epileptics. 

Treatment. — If the nasal membrane is diseased and if hypertro- 
phies, polypi, etc., are present to account for increased, retained, and 
perverted secretions, suitable treatment, such as has already been dis- 
cussed for these conditions, may remove the disgusting symptom, but 
if the cause lie in the nerve or its origin, or exist in the imagination 
as an hallucination, the indications for treatment are not so plain. If 
the olfactory bulb is the seat of the disease, galvanization or faradiza- 
tion, as mentioned for anosmia, may prove beneficial. 

Deformities and Diseases of the Nasal Septum. 

Exostoses, ecchondromata, and synechias have already been con- 
sidered and are illustrated by Figs. 25 and 26 and Plate III. It is 
unusual to find a nose with an interior that is architecturally sym- 
metrical. The septum in many instances is either curved (Figs. 51 to 



94 



DEFORMITIES OF THE NASAL SEPTUM. 



57), thickened, or even doubly curved so as to present a sigmoid flexure 
or a corrugated appearance. If the deformity is not sufficient to 
produce pressure on the turbinate bodies and consequent irritation, 
epistaxis, and obstruction to nasal respiration (Plate III), no symp- 
toms referable to the anomaly are present. According to Zuckerkandl, 
the septum is not found deviated before the seventh year, but the 
author has under observation a boy 5 years and 9 months of age with 
deflection, spurs on both sides, hypertrophied turbinals, and adenoids. 
The causes of malformed septa are not known, but the theories 




Fig. 51. — Moderate Deflection of the Septum Nasi. The deflection 
generally involves more or less of the cartilaginous portion of the septum 
and may extend to its anterior, free border. In the latter case the lumen 
of the anterior naris is diminished, and the breathing space is seriously 
encroached upon. 

are many. 0. B. Douglas believes that ""traumatism is a more frequent 
cause than all the others combined. Pressure at birth is doubtless a 
cause in certain cases" (The Laryngoscope, March, 1898). J. W. 
Gleitsmann attributes deflections of the septum nasi to the pressure 
upon the septum from below by the abnormally high arch of the roof 
of the mouth, occasioned by mouth-breathing in consequence of 
adenoid vegetations in the vault of the pharynx. The deflection may 
be so exaggerated as to give a twisted or bent appearance to the whole 
nose. The irregularity is limited generally to the anterior and middle 
sections of the septum. 



DEFORMITIES OF THE NASAL SEPTUM. 



95 



Symptoms of nasal irritation — epistaxis, discharges, reflex neu- 
rosis (such as asthma), nasal voice, naso-pharyngeal catarrh, etc. — 
result from considerable septal deformities. The diagnosis is readily 
made on inspection with brilliant, reflected illumination. 

Treatment. — If the deformity is limited to the cartilaginous sep- 
tum the most satisfactory procedure in my experience has been the 
amputation of the offending projection by means of the septum-knife 
(Fig. 38). The method is described in connection with the figure. 
We have always taken pains to avoid perforating the septum, but we 




Fig. 52.— Deflection of the Septum Nasi Sufficient to Cause Stenosis 
of the Left Nostril; Capacious Right Naris at the Expense of the Left 
Nostril. In this condition pressure of the septum on the turbinals may 
cause sufficient reflex irritation to provoke asthma, hay fever, ocular dis- 
turbances, and other reflex neurasthenic symptoms, 



have seen many cases in which surgeons had made large apertures 
without any unpleasant consequences. When the bony partition is 
involved the saw or trephines are called for. Various punches have 
been constructed to fracture and restore the deviated septum, after 
which bougies (Fig. 24), splints, and tampons are employed to main- 
tain the reduced deformity in proper position. 

C. G-. Coakley prefers the operation devised by Morris J. Asch for 
correcting deviations of the nasal septum. Special instruments for 
this purpose are required as follow; Straight and angular scis- 



96 



DEFORMITIES OF THE XASAL SEPTUM. 



sors, compression forceps, elevator, gouge, and tubular splints. One 
uses the scissors first to cut the cartilage along the line of greatest 
deviation, and, second, to bisect the first incision at a right angle to its 
centre. Then the index finger is used to force each resulting segment 
into the nasal median line, fracturing each quadrant at its attached 
base. The forceps are used to straighten any deviation posterior to the 
site of the operation. A large, hollow splint is inserted into the for- 
merly obstructed fossa, and is worn for four or five weeks, being 




Fig. 53.— Deflection of the Septum Nasi Toward the Right Side, at 
Nearly a Right Angle. Such deformities are characteristic results of frac- 
tures of the osseous septum by falls or blows upon the nose, particularly 
in childhood. The pressure on the opposing turbinals results in their 
atrophy, while the opposite turbinated bodies are often found hyper- 
trophied. 



removed frequently for necessary cleansing. The elevator and gouge 
are employed to divide adhesions. Emil Mayer has reported two hun- 
dred cases of the Asch operation "all of them permanently benefited." 

The writer has made use of the same principle in correcting de- 
formed nasal septa, with the most satisfactory results. Gleason and 
others have devised useful operations. 

J. Price-Brown employs silver tubes to correct septal convexities. 
"The advantage of silver tubes lies in their lightness, aseptic character, 
smooth surface, and the fact that a silversmith can form one to suit 



DISEASES OF THE NASAL SEPTUM. 



97 



each case. The open tube enables the patient to breathe through it. 
A small bulge on its outer wall will insure its retention, and the 
patient soon learns to remove and cleanse it and replace it daily. 
("Diseases of the Xose and Throat," 1900.) 

BLOOD-TUMORS OF THE NASAL SEPTUM. 

Haemorrhage from blows, etc., takes place between the mucous 
membrane and the. cartilage. Fractures of the septum occasionally 
result in hsematomata. These tumors are easily recognized and 




Fig. 54. — Deflection of the Septum Nasi Toward the Left Side with 
Apparent, but not Real, Adhesion to the Left Inferior Turbinated Bone. 
Such deformities extending throughout the cartilaginous portion of the 
septum are accountable for the tilting of the tip of the nose to one side 
of the median line, producing the crooked-nose deformity. 



should be opened before their contents degenerate into a purulent 
mass, resulting in abscesses. (See "Treatment" under "Abscess," 
below.) 



ABSCESS OF THE NASAL SEPTUM. 



Like blood-tumors, abscesses are generally in the cartilaginous 
portion of the septum. They may assume such proportions as to com- 
pletely blockade the nostrils and compel mouth-breathing. In a case 
recently under my care the swellings were symmetrical and had at- 



98 



PERFORATION OF THE XASAL SEPTUM. 



tained such a size as to protrude sufficiently from the nostrils to be 
plainly visible. They are usually the result of blows, and their his- 
tory and appearance render the diagnosis easy. 

Treatment. — Abscesses of the septum, like blood-tumors, should 
be opened, their contents evacuated, and the cavities cleansed with 
hydrozone. Then equal parts of alcohol and tincture of iodine should 
be injected so as to wash out the cavity. The dressing is completed 
by packing aristol gauze between the opposite wall and the septum 
so as to cause coaptation of the separated mucous membrane to the 




Fig. 55. — Perpendicular Portion of the Ethmoid Bone, Consisting of Two 

Plates; the Inferior Turbinated Bone of the Left Side 

is Plainly Visible. 

cartilage again. This method may prevent perforation of the carti- 
lage, which is a frequent sequel of these diseases. 



PERFORATION OF THE XASAL SEPTUM. 

An aperture is not infrequently found in the cartilaginous part 
of the septum when patients are unaware of its presence (see Plate 
II), but occasionally a small perforation causes a whistling sound as 
the current of air moves rapidly over it, annoying the patient and 
attracting the attention of others. A prominent educator of my ac- 
quaintance was troubled in this manner. He was apparently in excel- 



PERFORATION OF THE NASAL SEPTUM. 



99 



lent health and there was no assignable cause for the anomaly. Per- 
forations are usually considered as indicative of syphilis, but they are 
not necessarily so. We have often been unable to trace them to any 
specific taint. They may occur as the result of impaired nutrition 
•or the habit of picking the nose with the fingers. Abrasions are pro- 
duced, and the crusts that form over them are not allowed to remain 
until healing occurs beneath. In the course of exhausting diseases, 
-such as tuberculosis and typhoid pneumonia, the septum may become 
perforated. 




Fig. 56. — Transverse Vertical Section through the Nasal Fossae. 1, 
Deflected septum nasi in contact with the left inferior turbinated body. 
Its deflection toward the left side has caused atrophy of the left middle 
turbinal, and has permitted an hypertrophy of the right middle turbinal. 
2, Two maxillary antra of the left side, while there is only a single one on 
the right side. 

Treatment. — Unless the perforation causes a whistling sound per- 
ceptible to others or annoying to the patient, no treatment is required 
except the application of benzoinol or some stimulating ointment to 
the border of the perforation. Treatment does not result in its 
-closure. If disagreeable sounds are produced the opening can be 
changed in shape so that its long axis shall correspond to the air- 
eurrent. 

In operations on the nose Delavan (Journal of Laryngology, 
1895) deprecates perforating the vomer on account of the dispropor- 



LrfC. 



100 



FRACTURES OF THE NOSE. 



tionate shock resulting. French (New Yor'k Medical Journal, De- 
cember 1, 1894) perforates the septum when necessary for breathing- 
space, but insists on proper after-treatment, and Wright insists on 
thorough antiseptic treatment before and after operations on the nose. 



Fractures of the Xose. 

The bones of the nose are not easily or often broken. The arched 
contour and the cartilaginous portion serve to protect against such 




Fig. 57. — Transverse Vertical Section through the Nasal Cavities. 1, 
Ethmoid cells. 2, Right maxillary antrum. 3, Deflected septum, and spur 
with adhesions (synechiae) to the inferior turbinal and to the floor of the 
meatus. 4, The maxillary antrum should be above this line, but it is 
absent. 



accidents. A blow or fall upon the nose sideways, however, may drive 
the bones inward and produce deformity, or a powerful force, like the 
kick of a horse, may shatter the osseous arch. The deformity pro- 
duced by such accidents is shocking. The sense of smell is likely to 
be destroyed on account of the damage done to the olfactory nerves. 
Examination under ether will reveal the nature and extent of the 
injury, which is readily apparent. The fact that such accidents are 
liable to produce concussion of the brain should not be lost sight of 
in forming a prognosis. 



FOREIGN" BODIES IN THE NOSE. 101 

Treatment. — Pain, bleeding, oedema, swelling, and emphysema 
of the tissues demand immediate attention to check' the haemorrhage, 
relieve the pain, and reduce the swelling. Anodynes and the icebag 
(Fig. 194) meet these requirements. Then the fractures must be re- 
duced to as perfect coaptation of the parts as possible, since nasal 
deformity, above all others, influences the business and social in- 
terests of the patient. The pure-silver Eustachian catheter can be 
bent to the proper shape and inserted beneath the depressed bones 
to elevate them to their correct level, while the fingers of one hand 
support them from without and assist in nicely adjusting them. If 
restored to their normal relations they remain so, since there is no 
muscular contraction to again displace them. Union usually takes 
place rapidly. 

Congenital Deformities of the Nose. 

These are exceedingly infrequent occurrences. If a deformity 
consist of an impervious membrane of the posterior nares it must be 
perforated to establish nasal respiration. 

Deformities which involve a depressed condition of the nasal arch 
may be so far corrected as to convert an unsightly member into a 
comely form. This is accomplished by Gersuny's method of injecting 
paraffin under the skin covering the saddle-back deviation from the 
normal lines. With an Eckstein syringe the paraffin is introduced at 
a temperature varying from 108° to 115° F., preferably at 111° F. 
Then the raised portion of the skin is molded into the proper contour 
over this body of paraffin, which sets, and sustains the superimposed 
integument in the form desired. 

Foreign Bodies in the Nose. 

The nose, like the ear, is a favorite receptacle for foreign bodies 
introduced by children and the insane. Beans, peas, pebbles, etc., are 
not infrequently found lodged in these cavities. The act of vomiting 
occasionally forces the ejected matter into the post-nasal space. Bodies 
inserted into the nostrils are generally located near the vestibule in 
the inferior meatus and are readily seen on inspection. Sneezing, 
lacrymation, nasal obstruction and discharges are the symptoms that 
point toward the invader. Berries so absorb the serum and swell that 
their increased calibre and the tumefaction of the mucous membrane 
occlude the offended nostril. Unless the body is removed it provokes 



102 



FOREIGN" BODIES IN" THE NOSE. 



inflammation and ulceration, with frontal and facial neuralgia and a 
purulent discharge more or less discolored with blood. The inflamma- 
tory process may extend backward to the post-nasal space and to the- 
opposite nostril, compelling oral respiration and causing loss of smell, 
and impairment of hearing from involvement of the Eustachian tube. 
Decomposition of the retained secretions causes a fetid odor and the 
occasional expulsion of cheese-like masses. 

If the obstructing body has been crowded or snuffed backward 
into the middle portion of the meatus, it may be shielded from view 
by the swelled turbinal or by a covering of the discharges. The secre- 
tions should be soaked up by the careful application of absorbent 
cotton on the carrier. This is better than to syringe or spray the nose r 
for there is less liability of forcing the body farther out of reach. 




Fig. 58. — Hartmann's Forceps. 



After drying the cavity a 10-per-cent. solution of cocaine is applied 
to the tumefied turbinal, so as to contract it and afford a view of the 
whole interior of the cavity. Suprarenal extract will serve the same 
purpose. The probe will then detect any alien substance. 

Treatment. — Foreign bodies should be removed as early as pos- 
sible to prevent serious consequences. This can generally be accom- 
plished by angular forceps (Fig. 58). They should be applied with 
care not to crowd the body farther inward. It is best not to close the 
jaws of the instrument until one is certain that it embraces the body 
a little beyond its centre, otherwise it is likely to slip off, and in doing 
so propel the body still farther from view. In the case of a berry of 
a plant, like the bean, that has become softened and enlarged by the 



MAGGOTS IN THE NOSE. 103 

absorption of moisture, a sharp hook like the one found in the author's 
middle-ear case (Fig. 181) can be made to imbed itself in the substance 
of the body and glide it out of the canal. In some instances a blunt 
hook, the snare, and mouse-tooth forceps offer decided advantages. 

Maggots in the Nose. 

This is a condition rarely found except in tropical climates. The 
eggs of flies are deposited in or about the nares, maggots are hatched, 
and destruction of the soft tissues and even of the nasal bones ensues. 
M. A. Goldstein reported having removed over 300 larvae from the 
nose of a patient who had been infected by a blow-fly (The Laryngo- 
scope, December, 1897). Itching, crawling, gnawing sensations and 
intense pain are experienced. A bloody, purulent discharge of fetid 
character appears. The intense inflammation may invade the sur- 
rounding structures, causing redness and oedema of the face and men- 
ingitis, with convulsions, coma, and death. 

Diagnosis. — Inspection readily reveals the cause of the trouble. 

Treatment. — Chloroform is the most efficient remedy. Inhala- 
tion may be sufficient to destroy the larvae; if not, it should be in- 
jected into the nose after enough has been inhaled to prevent pain. 
This is made to syringe out all the maggots and effectually empty the 
cavities. William Scheppegrell found that oil freely sprayed into the 
nostrils killed the larvae (The Laryngoscope, February, 1898). After- 
treatment should be attended to according to the condition present 
until the health of the membrane is restored. 



CHAPTER VIII. 
DISEASES OF THE ACCESSORY CAVITIES OF THE NOSE. 

Inflammation of the Antrum of Highmore, or 
Maxillary Sinus. 

This disease occurs sometimes as a complication of acute rhinitis, 
and if severe is accompanied by a sense of uneasiness or pain and 




Fig. 59. — Transverse Vertical Section through the Nasal Fossae and 
Maxillary Antra. 1, Superior turbinated body united to the middle turbi- 
nal. 2, Polypoid growth from the shelving outer wall of the fossa. 3, 
Inferior turbinated body. 4, Tumor in the maxillary antrum. 



tenderness in the antral, orbital, and frontal regions. These symptoms 
are more common when there is obstruction to the outward flow of the 
secretions. If the disease does not subside coincident lv with the sub- 
sidence of the rhinitis, a chronic suppuration results, or empyema. 
It may arise as a sequel to diseases of the teeth, especially the first 
and second molars, or in connection with the eruptive fevers and 
syphilis (see Fig. Go). 
(104) 



INFLAMMATION OF THE MAXILLARY SINUS. 



105 



This affection is generally unilateral. Examination reveals a 
purulent discharge in the middle nasal meatus and its foul odor is 
noticed by the patient, showing the difference between this and ozaena, 
in which the sense of smell is destroyed. Empyema of long standing 
affects the general health to such a degree that a constitutional dis- 
turbance is readily apparent, and tumors sometimes develop (Figs. 59 
and 60). 

Diagnosis. — This is facilitated by the use of suprarenal extract 
or cocaine in the nose to contract the turbinate. If a rhythmic pulsa- 




Fig. 60. — Transverse Vertical Section of the Nasal Fossa?. 1, Eth- 
moid cells. 2, Deflection and spur of the nasal septum, probably the re- 
sult of a fracture separating the two plates of which this bone consisted; 
the consequent pressure on the left turbinals has caused their atrophic 
condition. 3, Tumor in the antrum of Hisrhmore. 



tion is seen in the pus lying in the middle meatus, antral suppuration 
is suggested. The pus should be removed and observation made to de- 
termine if it reappear from the antral cavity, issuing from below the 
middle turbinal. Pressure over the maxillary sinus or tapping upon a 
tooth may reveal tenderness. If hydrogen dioxide (peroxide) can be 
injected into the antrum through the opening beneath the middle 
turbinal, the usual effervescence will disclose the presence of pus, 
and is likely to cause pain. In exploring the antrum some operators 
prefer to enter the cavity through the socket of a tooth, which may 



106 



INFLAMMATION OF THE MAXILLARY SINUS. 



need to be sacrificed for this purpose, while others open the wall of the 
inferior meatus. Still others perforate the thinner wall of the middle 
meatus, under cocaine, going outward and downward to avoid the 
orbit. Then the author's aspirator (Fig. 179) may succeed in pumping 
the pus from the cavity. The patient is instructed to make a con- 
tinuous effort, as in pronouncing the consonant part of 1c, so as to ele- 
vate the palate and close the post-nasal space. Then the air-pump is 
manipulated, to prove the presence of pus. 

A purulent discharge from the antrum, when due to dental origin, 
is fetid; but when it is from other sources, like the ethmoid and 




Fig. 61. — Transverse Vertical Section through the Maxillary Antra. 
a, a, Antra of Highmore. b, b, Very thin alveolar process, allowing the 
teeth to nearly penetrate the floor of the antra. 



frontal sinuses, it is creamy and almost without odor. (L. C. Cline, 
Journal of the American Medical Association, September 23, 1899.) 

Prognosis. — This is not an inspiring one. The nature of the 
case is unfavorable for spontaneous resolution, and if the bone is 
necrotic a tedious time is to be expected. Otherwise the prognosis is 
good. 

Treatment. — As a complication of acute rhinitis, the treatment 
for the latter is indicated. If the mouth of the sinus is closed it should 
be cleansed with the antiseptic sprays, mentioned in Chapter I, with 
diluted hydrozone, and then moistened with a cocaine solution to 
contract the tissues and open the hiatus. If there is much pus in the 






INFLAMMATION" OF THE MAXILLARY SINUS. 



107 



antrum or if it is inspissated, it is not an easy matter to evacuate and 
cleanse the sinus through the ostium maxillare. The opening is so 
small that it may be necessary to penetrate the bone. Some operators, 
like the late Moses G-unn, make a crucial incision in the cheek, and 
perforate through the canine fossa, but it is better to penetrate 
through the alveolus of a tooth, especially if it prove to be the exciting 
cause of the trouble (Figs. 61 and 62). 

The weight of argument and experience is in favor of entering 
the sinus through the nose, just below the natural opening. The 
cannula and trochar (Fig. 63) are best adapted for this purpose, for 
the cannula can be left in position until the cavity is thoroughly 




Fig. 62. — Transverse Vertical Section through the Maxillary Antra, 
showing on Either Side that an Operation to Open the Antrum through 
the Socket of a Tooth Would Eesult in Penetrating the Nasal Cavity In- 
stead of the Antrum of Hisrhmore. 



cleansed and medicated. The after-treatment should be conducted 
similarly to the medicinal treatment detailed for middle-ear suppura- 
tion. 

The writer has devised a combination of cannula and spray-tips 
which render good service (Fig. 64). They are an adaptation of the 
Davidson or De Vilbiss atomizer fitted with spray-tips having very 
large openings, and the outer tip being turned to fit closely into the 
conical opening of a special cannula. The latter is made of silver, and 
is practically a modification of the Eustachian catheter. Instead of 
having the beak curved on the arc of a large circle, like that of the 
catheter, it is bent on the arc of a very small circle, so as to allow of 
its introduction into a narrow space. This arrangement of the beak 



108 INFLAMMATION OF THE MAXILLARY SINUS. 

is required for the purpose of introducing it into the maxillary antrum, 
either through the ostium maxillare or through an artificial perfora- 
tion: for instance, the opening made by way of the socket of a tooth. 
The outer spray-tip is so nicely adjusted to the conical mouth of the 
cannula that there is no leaking at their junction, although the first 
ones made were defective in this respect; but a small piece of rubber 
tubing fitted over the outer spray-tip, to join it with the cannula, pre- 
vents the leaking. The inner spray-tip can be dispensed with. 

When fluids are thrown through the cannula they escape from its 
beak in the form of a very profuse spray, which approaches the char- 
acter of a stream in effect. It is so copious, in fact, that it deluges the 
cavity into which it is projected, and with an air-pressure of only 
eight pounds the full bottle of the detergent solution is emptied within 
a minute. The same tips, used without the cannula, are valuable for 
flushing the nasal fossae. 

By means of this antrum-spray some cases of suppuration of the 
antrum of Highmore can be cured without making an artificial open- 




Fig. 63. — Cannula and Trochar. 

ing; but the apparatus is just as effective for washing out the antrum 
after an operation. By rotating the beak of the cannula, introduced 
through the artificial opening, the walls of the cavity can be thor- 
oughly cleansed and medicated, as I have demonstrated many times. 

If the cannula is to be used in the ostium maxillare, the opening 
of the antrum is first located, the cannula is introduced, and the latter 
is then marked at the point corresponding to the tip of the nose. This 
mark, in any given case, facilitates the introduction of the cannula 
afterward. 

The same apparatus is useful in treating suppurative inflamma- 
tion of the ethmoid cells, the beak of the cannula being directed up- 
ward so as to throw the coarse spray into the cells. Some patients with 
disease of the frontal sinuses have claimed that they could feel the 
spray from the cannula enter the sinuses. I have not felt certain, how- 
ever, that they were not mistaken. This instrument has proven to be 
effective, also, in washing out cholesteatomatous masses from the attic 
of the tympanic cavity. 



ETHMOID DISEASE. 



109 



After cleansing the suppurating surfaces, various powders — such 
as boric acid, aristol, and nosophen— are blown through the cannula 
to the diseased parts. When used as an attachment to the powder- 
blower the cannula must be dry; hence it is advisable to have more 
than one for use in the combined wet and dry treatments. 

Miscellaneous. — Phlegmonous inflammation of the antrum is a 
very rapidly fatal form of inflammation. 

Tumors of the antrum are exceedingly rare, but require extirpa- 



tion through the anterior wall. 



(See Figs. 59 and 60.) 




Fig. 64. — The Author's Antrum and Ethmoid Irrigator. 



Ethmoid Disease. 

An inflammation of the nasal membrane sometimes extends into 
the ethmoid cells (Fig. 65), the membrane of which, like that of the 
mastoid cells, lines the osseous cavities and serves as a periosteum. 
Hence an inflammation of this membrane is readily communicated to 
the bony walls themselves, resulting in caries and. necrosis. Pain is 
referred to the root of the nose and the orbital and temporal regions. 
The disease may extend so as to produce a bulging prominence be- 
tween the eye and the root of the nose, and the eyeball may protrude 
abnormally. In a girl of 17 years, in bad general health (Fig. 71), the 
arch of the nasal bones was widened, the vault of the nose was filled 
with mucous polypi, and the flow of the mn co-purulent discharge was 



110 SPHENOID DISEASE. 

enormous, necessitating the carrying about of a bundle of cloths in- 
stead of a handkerchief. There were also adenoids in the vault of the 
pharynx, hypertrophied tonsils, and chronic suppuration of both mid- 
dle ears. The polypi, adenoids, and tonsils were removed, but the 
polypi were reproduced with mushroom-like rapidity. The ethmoid 
cells were opened up and curetted, and she improved satisfactorily. 
The discharges from the ethmoid cells and ears ceased. 

Diagnosis. — The antrum of Highmore is often involved coin- 
cidently, and it is sometimes difficult to make a differential diagnosis 
between the two. However, the pain in ethmoiditis is referred to the 
root of the nose and back of the eye, and the eye symptoms help to 
clear up the uncertainty. The discharge is generally seen where it 
occurs in antral suppuration, but the smell, in this disease, is more 
likely to be impaired or lost. 

Prognosis. — When ethmoiditis is a simple concomitant of acute 
rhinitis it subsides together with the principal disease. Suppuration 
is a serious condition, for it may invade the orbit or extend to the 
cerebral meninges. 

Treatment. — Antiseptic, detergent washes already given in the 
first chapter — consisting of hydrozone, etc. — must be employed for 
cleansing purposes. All polypi should be removed and then I make 
use of the curettes shown in Fig. 201 to scrape out carious and necrotic 
tissue. If the middle turbinate body is too large to admit of proper 
observation and manipulation, it must be removed, as already de- 
scribed. The anterior ethmoid cells are in communication with this 
turbinal; hence the advantage of its excision. After-treatment is the 
same as for antral suppuration. (See description of Fig. 64.) 

Polypi sometimes take their origin from the ethmoid cells, pro- 
ducing pressure on the surrounding structures. The result is apparent, 
especially in the increased breadth of the nose and the prominence 
of the eyes (Fig. 71). Osteomata produce like appearances. The treat- 
ment for growths in this locality consists in extirpation. (See "Treat- 
ment" of "Nasal Polypi.") 

Sphenoid Disease. 

It may be observed that I have departed from the custom of add- 
ing "al" to the adjectives ethmoid and sphenoid. This is because it 
is etymologically correct to do so; it is in keeping with the American 
tendency to brevity and terseness, and in conformity witli the com- 
mon use of the corresponding term "mastoid'' instead of "mastoidal. M 



SPHENOID DISEASE. 



Ill 




Fig. 65. — Longitudinal Vertical Section (Actual Size) through the 
Nasal and Accessory Cavities. (Author's Specimen.) 1, Right termina- 
tion of the left frontal sinus. 2, Right frontal sinus. 3, Probe extending 
from the right frontal sinus through the infundibulum into the right 
nasal fossa. 4, Ethmoid cells. 5, Large opening into the maxillary sinus. 
6, Anterior antrum of the sphenoid bone. 7, Posterior sphenoid antrum. 
8, Middle nasal meatus. 9, Inferior meatus. 10, Inferior turbinated bone. 
11, Probe extending through the nasal duct. 



112 DISEASES OF THE. FRONTAL SINUSES. 

These terms are Greek adjectives merely transferred into English, and 
are not rendered more perfect by additional terminations. 

Sphenoiditis occurs as a complication or sequel of inflammation 
of the nasal accessory cavities (Fig. 65) and of meningitis. The 
symptoms are not pathognomonic and this affection is difficult to 
differentiate from disease of the ethmoid cells. The pain is deeply 
seated, the discharge empties into the throat, and dimness of vision, 
strabismus, and prominence of the eyeball are symptoms characteristic 
of this disease. 

The throat-mirror may reveal pus escaping from the sphenoid 
antrum into the naso-pharyngeal cavity. Schaerfer, of Bremen, has 
reported a large number of these cases, and gives the symptoms of the 
chronic cases as follow: Fetor, dizziness, supra-orbital neuralgia, stiff 
neck, or general pressure of the head or occiput. The .pain is inter- 
mittent and may produce nausea and vomiting. He never found eye 
trouble. (Oscar Dodd, in The Laryngoscope, May, 1901.) 

The prognosis is unfavorable on account of the tendency to in- 
vade the cranial cavity (Fig. 66). 

Treatment. — The methods already described for diseases of the 
accessory cavities are applicable here. If it should become necessary 
to open and curette the sphenoid sinus (Figs. 65 and 66), the instru- 
ment should be passed over the middle turbinal, backward and upward, 
until it enters the lower part of the cavity. The sinus can be opened 
through its under wall also by perforating through the pharyngeal 
vault immediately back of the posterior nares. Subsequent treatment 
has been indicated in treating of the other sinuses (Fig. 64). 

Tumors are rare in the sphenoid sinuses, but if they produce 
blindness or other serious symptoms they must be removed. 

Diseases of the Frontal Sinuses. 

Inflammation of these cavities (Figs. 65 and 66) occurs mostly 
from extension of rhinitis. It is not to be expected under the twen- 
tieth year, since these sinuses, being developed from the anterior eth- 
moid cells, are not formed earlier. Acute inflammation is charac- 
terized by a severe, continuous, frontal headache and pain about the 
eyes. There is tenderness over the sinuses on percussion, and on 
pressure beneath the supra-orbital ridge. Nausea and vomiting are 
occasionally present. The pain may not Ik- due entirely to the swelling 
of the mucous membrane lining the cavities, but to the loss of the 



DISEASES OF THE FRONTAL SINUSES. 



113 



natural air-pressure, for I have observed that the propelling of air 
impregnated with a nebula of camphor-menthol into the sinuses gave 
decided relief. 




Fig. 66.— Longitudinal Vertical Section (Natural Size) through the 
Nasal and Accessory Cavities. (Author's Specimen.) 1, Left frontal 
sinus. 2, Termination of the right frontal sinus. 3, Crista galli. 4, Crib- 
riform plate of the ethmoid bone. 5, Perpendicular plate of the ethmoid. 
6, Part of the anterior sphenoid antrum. 1, Posterior sphenoid antrum. 
8, Vomer. 9, Palate bone. 



114 DISEASES OF THE FRONTAL SINUSES. 

When the infundibulum, or passage between the nasal and frontal 
cavities (Fig. 65), becomes clogged, the retained secretions, mucus or 
pus, will cause great pain. The pressure may be sufficient to cause 
absorption of the osseous partition separating these sinuses, or bulging 
may take place downward and outward so as to encroach and press 
upon the eyeball. 

Suppuration of the frontal sinuses is an infrequent disease. The 
pus can be seen in the middle meatus under good illumination, flow- 
ing downward from the region of the sinus-opening. It should be 
wiped away and the area watched to see the source of the discharge. 
If the pus break through the posterior wall of the sinus, there are 
symptoms of brain-compression, drowsiness, headache, stupefaction, 
etc. This complication induces purulent meningitis. 

The symptoms point quite distinctly to the seat of the trouble, 
and are not so obscure as in sphenoiditis. The electric lamp and con- 
denser of Heryng are useful in making diagnoses in this class of dis- 
eases. Transillumination of the frontal sinus is accomplished by ap- 
plying the lamp to the lower border of the supra-orbital ridge and 
inner angle of the orbit in a dark room. In health the sinus is illu- 
minated up to the superciliary ridge, but in case of the presence of 
pus it is dark. 

Treatment. — The first indication is to subdue the pain. If the 
inflammation occur in the course of acute rhinitis the treatment for 
that is appropriate and effective here. An application of suprarenal 
extract or cocaine to the sinus-opening may so contract the swollen 
tissues as to open the duct, give exit to the pent-up secretions, and 
relieve the pain. The detergent, antiseptic sprays given in Chapter 
I are useful in this affection. After cleansing the cavities by sprays 
and having the patient repeatedly blow his nose, great relief is afforded 
by throwing a nebula of a 10-per-cent. solution of camphor-menthol 
in lavolin or benzoinol into the nostrils, with the air-current directed 
toward the naso-frontal duct. This tends to evacuate any retained 
secretions and to restore the normal air-pressure in the sinuses, besides 
medicating the remote membrane as ordinary treatment fails to ac- 
complish. (See description of Fig. 64,) 

In the acute stage an icebag (Fig. 194) is indicated to subdue 
and avert the inflammation. It should be applied over the frontal 
protuberances and the root of the nose. If this should not afford 
relief, or if it prove irritating, hot fomentations may be substituted. 
Any obstructing hypertrophies or tumors must be removed, as pre- 



DISEASES OF THE FRONTAL SINUSES. 115 

viously described. If the discharge contained in the sinuses cannot 
be liberated by opening the naso-frontal duct with air-pressure, co- 
caine, or a probe, it may be necessary to penetrate the sinus directly, 
near the internal angle of the orbit, at which point the cortex is quite 
thin. 

This procedure is similar to that which has already been detailed 
for opening the mastoid antrum and removing the diseased contents. 

"Trephines and drills are preferred by some surgeons, but the 
simplicity and ease of tho manipulations of chisel, gouge, and mallet 
entitle these instruments to the preference." (Robert Sattler.) 
Tumors of the frontal sinuses are treated on the principles already 
laid down for tumors of the other accessory cavities. 



CHAPTER IX. 

RELATED DISEASES OF THE EYE AND NOSE. 

Foe many years it has been recognized that diseases of the eye 
and of the nose were often associated and interdependent. In certain 
cases pathological conditions originate in the nose and extend, by 
continuity of tissue or by migration of morbific germs, to the eye. 
Occasionally the reverse process occurs. More recently reflex ocular 
disturbances arising from nasal affections have received attention. 

When one considers the close relationship existing between the 
eye and the nose and its adjoining cavities, it is not surprising that 
morbid conditions of these parts are closely related. The mucous 
membrane of the eyeball and lids is continuous with that lining the 
lacrymal sac, the nasal duct, and the nasal and connecting cavities 
(Fig. 67). The eye is in close proximity to these cavities, and the 
blood- and nerve- supplies of the nose and eyes are intimately con- 
nected with each other. The nasal duct is the drainage-canal of the 
eye, through which the surplus moisture of the latter is emptied into 
the nose. Hence, organisms inhabiting the nose or its accessory 
sinuses and antra may migrate through the nasal duct to the eye 
(Fig. 68), and, conversely, disease-germs that lodge in the eye may 
pass through the lacrymal sac and the nasal duct to the nasal fossa, 
there to set up their pathological processes. 

In health there is a free communication between the nose and 
the eye; so much so that inflation of the nasal cavities may cause the 
air to pass through the nasal duct, the lacrymal sac, and canaliculi to 
the eye. Indeed, the author remembers to have seen the loose areolar 
tissue about the eye, the side of the nose, and the upper part of the 
cheek made greatly emphysematous after a nasal inflation, due to 
rupture of the lacrymal sac. The swelling occasioned no inconven- 
ience, and it subsided in a few hours. This case illustrates the ease 
with which morbific material may be propelled from the nasal cavity 
through the patulous nasal duct to the eve by the acts of sneezing 
and inflation of the nasal fossa? by the Valsalvan experiment and by 
blowing the nose. From this cause may originate inflammatory affec- 
tions of the lids, cornea, or sclera. 
(110) 



RELATED DISEASES OF THE EYE AND NOSE. 



117 



In order to set forth fairly the present status of opinions on this 
subject among ophthalmologists we will refer to the experiences of 
several authors. 

W. F. Mittendorf says: "Inflammatory conditions of the lining 
membrane of the nose are, perhaps, the most frequent of all the causes 
of inflammatory actions in the tear-passages. How often do we not 
see diseases of the conjunctiva or cornea, especially those that are 
accompanied by lacrymation, followed by inflammation of the Schnei- 




Fig. 67. — Dissection showing Nasal Duct and its Kelations. 1, In- 
ferior turbinate bone. 2, Nasal duct and valves. 3, Middle turbinate 
body. 4, Lacrymal sac. 5, Lacrymal canaliculi and their orifices. 

derian membrane; and, on the other hand, mild forms of conjunc- 
tivitis generally accompany catarrhal inflammation of the nose or the 
tear-sac." 

G-. E. de Schweinitz, in his work on the eye, 1893, says: "Dis- 
eases of the lacrymal sac are rarely primary. In nearly every case 
of disease of the lacrymal sac and of the laerymo-nasal duct morbid 
conditions of the nasal chambers and of the naso-pharynx are present. 
Although it might seem natural that conjunctivitis, and especially 
purulent conjunctivitis, should cause lacrymal disease, this is by no 



118 RELATED DISEASES OF THE EYE AND NOSE. 

means frequently the case. Conjunctivitis and blepharitis, so often 
accompanying diseases, follow rather than cause the lacrymal affec- 
tion. Obstruction of the duct and diseases of the sac are sequels of 
measles, scarlet fever, and especially small-pox, because these exan- 
themata are accompanied by inflammation of the nasal mucous mem- 
brane." 

George M. Gould says that in the vast majority of cases of related 
affections of the nose and eye the nose is the point of departure of 
the morbific process, the eye more seldom setting up disease in the 
nose. 

Bresgen observes that the nose is infrequently invaded in con- 
junctivitis, while the eye is implicated in coryza. 

Thomas F. Eumbold, in 1866, emphasized the importance of nasal 
catarrh as a cause of eye affections. 

Gruhn reports thirty-eight cases of daeryocysto-blenncrrhoea as- 
sociated with hypertrophy of the turbinals, spurs and deflections of 
the nasal septum, and atrophic rhinitis and pharyngitis. He attributes 
the lacrymal troubles to the nasal diseases. 

W. Franklin Coleman, of the Chicago Post-graduate Medical 
School, expressed his views in a private letter to me on February 4, 
1898, to the effect that in nasal inflammation, whether independent 
of or accompanied by hay fever, it is common to find the ocular con- 
junctiva hyperaemic or inflamed. Many cases of epiphora are not due 
to stenosis of the lacrymal passages, but to a nasal disease. Purulent 
inflammation of the lacrymal sac has its origin, as a rule, in a nasal 
disease, and rarely in an ocular affection. The extension of rhinitis 
to the nasal duct is followed by stenosis, decomposition of the con- 
tents of the sac, and suppuration. Asthenopia, occasionally, is not 
relieved by correction of refractive or muscular errors, neurasthenia, 
or other constitutional faults. In these cases relief comes through 
attention to the etiological factors: nasal diseases. Phlyctenular con- 
junctivitis and keratitis, though often essentially due to malnutrition, 
are so frequently accompanied by rhinitis and eczema of the lower lid 
and face that we may assume the nasal disease to be a causative factor 
of the ocular. Yet, in some cases the rhinitis seems to follow the ex- 
cessive lacrymation, just as the eczema of the lid and face follows the 
ocular disease and its attendant epiphora. 

R. W. Seiss has reported several cases of closure of the nasal 
mouth of the lacrymo-nasal duct caused by unskillful use of the cau- 
tery. The effect on the drainage of tears is evident. 



RELATED DISEASES OF THE EYE AND NOSE. 



119 



A number of illustrative cases are reported in the "American 
Year-book of Medicine and Surgery" for 1897. Among them is a 
case cited by Panas, in which there was double purulent dacryoadeni- 
tis, coincident with a severe tonsillitis and muco-purulent nasal ca- 
tarrh. Kamsey, in treating of lacrymal obstructions, advocates the 
necessity of examining the nasal fossae, of treating inflammatory or 
hypertrophic conditions found, and of investigating for a syphilitic 
history. 




Fig. 68. — 1, Middle turbinated body turned aside and held by a 
hook. 2, Nasal duet and valves. 3, Canal leading to the maxillary and 
frontal sinuses. 4, Inferior turbinated body showing location of the 
mouth of the nasal duct in the cul-de-sac. 



T. K. Hamilton found eye diseases in 51 out of 106 cases of post- 
nasal vegetations. In 6 of these there was blepharitis, in 7 follicular, 
in 16 granular, and in 22 catarrhal conjunctivitis. 

John Dunn believes that in the vast majority of cases of children 
suffering from phlyctenular troubles there will be found a coincident 
rhinitis, and behind this unhealthy adenoid vegetations. 

Samuel G. Dabney has seen obstinate cases of ciliary injection and 



120 RELATED DISEASES OF THE EYE AXD XOSE. 

lacrymation disappear immediately on removing a septal spur which 
was pressing against a turbinated body. Photophobia and asthenopia 
are occasionally caused by hypertrophic rhinitis. More grave diseases, 
such as glaucoma and organic affections of the optic nerve, have also 
been attributed to nasal influence. 

D. B. St. John Koosa, in his book on the eye, in treating of 
lacrymal catarrh, says that in a large proportion of cases it is a purely 
catarrhal affection, produced by the same causes that bring on catarrh 
in other parts of the naso-pharyngeal tract, colds in the head, and 
catarrhal conjunctivitis. 

Influenza has given rise to orbital cellulitis, and out of three such 
cases recently two have died of the influenza. 

Xieden maintains that phlyctenular keratitis almost invariably 
takes its origin from a disease in the nose. 

Puech observed instances of lacrymation occasioned indirectly by 
decayed stumps of teeth which set up chronic inflammation of the 
antrum of Highmore and the nasal fossa, thence extending upward 
into the nasal duct (Fig. 65). 

Herman Knapp records an instance of lupus extending from the 
nasal fossa toward the lacrymal canal, followed by dacryocystitis. 

Bresgen lays stress on the causal relation of nasal disease to stric- 
ture of the lacrymal canal, and insists that every lacrymating patient, 
even when he first visits an ophthalmic surgeon, rught immediately 
to be referred to a rhinologist for a scientific examination, and for 
eventual nasal treatment. 

Fischer attributes cases of chronic conjunctivitis, trachoma, iritis. 
keratitis, and glaucoma to ozaena; and gonorihceal ophthalmia has 
been traced to infection by way of the nose and the lacrymal canal. 

Guenod states that the pneumococcus, which is a normal resident 
of the upper, anterior air-passages, has been found in conjunctivitis, 
dacryocystitis, deep ulcers of the cornea, and in panophthalmitis. 

Guttman has reported a case of diphtheric conjunctivitis in which 
true diphtheric bacilli were found, occurring during an attack of 
measles, and which was complicated by corneal absress. purulent cellu- 
litis of the lids and cheek, and extension of the false membrane to 
the nose and throat. Antitoxin was injected early, but had no influ- 
ence whatever in staying the progress of the disease or in averting a 
fatal termination. On the other hand, Coppez and Funk speak, from 
a large experience, in the highest terms of the efficacy of serum- 
therapy in the treatment of diphtheric conjunctivitis. 



RELATED DISEASES OF THE EYE AND NOSE. 121 

An appearance of excessive lacrymation may be caused by an 
obstruction to the passage of tears into the nose, due to ethmoid dis- 
ease or pressure of a nasal polypus or other growth on the nasal duct. 
On account of this the tears flow over the lid and cheek (epiphora). 
Ethmoid disease may produce sufficient pressure to increase the dis- 
tance between the eyes, causing the globes to protrude, and giving 
the appearance known as frog-face (Fig. 71). These variations in the 
anatomical relations of the bones of the orbit and the recti muscles 
may produce disturbances of the functions of the eye, such as strabis- 
mus and astigmatism; or overdevelopment of the sphenoid bone may 
produce pressure on the optic nerve and impair or destroy its func- 
tions. Thus it will be seen that a growth in the nasal fossa., exceeding 
the natural limit of the cavity, may be the cause of serious ocular dis- 
turbances. 

Hansell referred acute, double optic atrophy in a young man to 
a purulent disease of the ethmoid and sphenoid cavities. 

Reflexes. — In 1882, and later, Hack called attention to the prob- 
ability of reflex ocular symptoms originating in pathological condi- 
tions of the nasal cavities. He also observed the causative relation 
of inflammatory conditions of the Schneiderian membrane to sick 
headache, neuralgia, cough, asthma, pain and swelling of the eyelids, 
and that, while the ordinary treatment for these latter affections was 
ineffective, they yielded to measures which restored the pituitary mem- 
brane to its normal condition. 

Eecently M. Georges Laurens has pointed out that more extended 
experience has added a large number of morbid phenomena to those 
that Hack regarded as taking their departure from nasal affections. 
Among these are epilepsy, vertigo, nightmare, sensations akin to those 
produced by a foreign body in the eye, heat, pricking, injection of the 
conjunctival blood-vessels, amblyopia, amaurosis, and photophobia. 

Numerous illustrative examples could be cited in which reflex 
irritation of branches of the fifth nerve occasions ocular disturbances, 
such as conjunctival irritation and lacrymation. When these symp- 
toms are OAved to diseased conditions of the inferior turbinated body 
they have disappeared on cauterization of the turbinal. On the other 
hand, Alt reports a case of optic neuritis consequent upon cauteriza- 
tion of the turbinals in a syphilitic patient. "The reflex troubles of 
motility consist of blepharospasm, strabismus, mydriasis, and asthe- 
nopia; the trophic disturbances consist in congestion of the conjunc- 
tiva, iritis, and glaucoma, while exophthalmic goitre may, in some 



122 RELATED DISEASES OF THE EYE AND NOSE. 

instances, be regarded as a condition associated with disease of the 
nasal mucous membrane. Contraction of the visual field has been 
observed by several practitioners. The affection of the eye is always, 
in accordance with the law of unilaterality, on the same side as the 
disease of the nose, though, in accordance with the law of symmetry, 
in some instances both eyes are affected, and in accordance with the 
law of intensity the eye primarily affected is always the most severely 
attacked." ("Year-book of Treatment," 1897.) 

The nasal diseases that are the most prolific of ocular manifesta- 
tions are chronic hypertrophic rhinitis, especially when there are con- 
tact, pressure, and even adhesions of the nasal septum and turbinals; 
acute rhinitis, inflammation of the membrane lining the sinuses con- 
necting with the nose, ulceration of the nasal membrane, ozama, and 
polypoid growths. "The reflex conditions that may be excited have 
reference to the sensibility of the eye, to the character of the secre- 
tions, to motility, and to trophic and vasomotor disturbances." 
(Laurens.) 

The effects of nasal hypertrophy, pressure, irritation, and conse- 
quent ocular and other disturbances were well exhibited in a some- 
what exaggerated case in the author's practice. A musician, 22 years 
old, presented symptoms of amblyopia and chronic non-suppurative 
inflammation of her middle ear, with subjective noises. The morbid 
manifestations were confined to her left eye and ear. The results of 
examination of these organs were negative, but there was an osseous 
adhesion between the left middle turbinated body and the septum 
nasi, and hypertrophy of the inferior turbinal of the same side. The 
patient suffered from frontal headache; and a most peculiar and in- 
teresting incident was a loss of power and uncomfortable sensations 
in her left arm, together with pain in her left side. The asthenic 
condition of her arm, combined with the impairment of vision, com- 
pelled the young lady to discontinue her piano-playing. After thor- 
ough electrocauterization of the inferior turbinal and the removal of 
the osseous synechia, not only did the eye and ear disturbances sub- 
side, but the neurasthenic symptoms referable to the left arm and side 
also vanished. Normal sight and hearing were restored, the subjec- 
tive noises ceased, the headaches disappeared, and the power and nat- 
ural sensibility of the arm returned. 

Henry D. Noyes, in his work on the eye, relates the case of a med- 
ical friend who suffered from asthenopia, headaches due to excessive 
strain of accommodation, heat at the vertex of the head, insomnia, 



RELATED DISEASES OF THE EYE AND NOSE. 123 

facial neuralgia following use of the eyes, and intense photophobia — 
a case of refractive and muscular and general nerve-exhaustion. There 
were extreme j^alpebral congestion and a tendenc}^ to lacrymation on 
exposure to light and attempting eye-work. The nasal passages were 
found to be narrow, with a slight protuberance of the septum from 
undue thickening, decided congestion, and tenderness on being 
touched. Anaesthesia b} r cocaine afforded relief in some measure to 
the eye : symptoms. Examination of the eye, after the fitting of glasses 
failed to afford relief, showed that there was much spasm of the ex- 
trinsic and ciliary muscles. Sprays, the ingredients of which were not 
mentioned, afforded relief. The patient was an asthmatic. After re- 
moval of the thickened portion of the se]3tum with a saw, marked 
improvement took place, and within four months the patient laid aside 
his glasses and was restored to a condition of comfort. 

Galezowski has seen persistent lacrymation caused by slowly 
growing exostoses of the nasal cavities. 

S. S. Bishop, of Pennsylvania, observes that discomfort of the 
eyes and lids and vasomotor disturbances are sometimes the reflex ef- 
fects of diseases of the nasal mucous membrane. He lays especial stress 
on spurs of the septum nasi and hypertrophy of the turbinate bodies 
as causes of these troubles. 

Cheatham is authority for three cases of asthenopia accompanied 
by other ocular symptoms. In each instance the ciliary weakness was 
found to be dependent upon local nasal trouble, such as catarrh, 
polypi, obstructions from deflected nasal septum, or engorged tissue. 
Ocular relief and strength immediately followed upon a cure of the 
nasal abnormality. 

Many sufferers from hay fever are attacked with itching of the 
lids, lacrymation, injection of the conjunctival vessels, and photo- 
phobia during the season of suffering. The first attacks of this disease 
are likely to be announced by the appearance of itching and suffusion 
of the eyes. 

Diseases of the eye are sometimes responsible for pathological 
states of the nose. Of 315 cases of functional nervous affections ex- 
amined by Miles with reference to eye-strain, 107 presented nasal 
symptoms, such as frequent sneezing, epistaxis, and annoying sensa- 
tions referable to the nasal fossae. Xearly all of these cases had errors 
of refraction. After relieving the ocular irritation by correcting the 
ametropia with proper lenses the nasal symptoms diminished or dis- 
appeared. This was particularly true of those cases characterized by 



124 



RELATED DISEASES OF THE EYE AND NOSE. 



asthenopia and headache. Ocular disturbances that cause a profuse 
flow of tears give rise to nasal hydrorrhcea and chronic rhinitis. 

Treatment. — When ocular disturbances are suspected of being- 
caused or perpetuated by diseases of the nasal cavities, — for example 
venous stasis, stenosis, or reflex irritation, — we may often be able 
to demonstrate the correctness of our conclusions by the application 
of suprarenal extract or cocaine to the diseased area. If it relieve the 
ocular symptoms, the line of successful treatment is indicated; but 
one had best bear in mind the case recorded by Marckwort, in which 
glaucoma followed a prolonged application of cocaine in the nose. 
Moreover, the author has met with cases in which the secondary effect 
of cocaine on the nasal mucous membrane was that of paresis of the 
blood-vessels, engorgement and complete nasal stenosis, with intensi- 
fied symptoms of hay fever. 

When obstruction to the free drainage of the tears through the 
nasal duct into the nose depends upon a disease of the nasal fossa, the 
latter must receive prompt treatment, as laid down in the foregoing 




^ L - i *"i — - -—* 



Fig. 69. — Lacrymal Knife. 



chapters. In all such cases the nasal cavities should be thoroughly 
examined without delay, and in many the nasal treatment alone will 
suffice to establish a normal condition. But the disease may have pro- 
gressed so far as to call for treatment addressed to the lacrymal drain- 
age-canal itself. Stenosis, fibroid adhesions, etc., may have produced 
permanent changes in the nasal duct or the lacrymal sac that will re- 
quire special attention from the ophthalmic surgeon. However, ten- 
tative treatment should be instituted first, and it may succeed in obvi- 
ating the necessity for surgical interference. 

The lacrymal sac can be emptied of pent-up secretions by gentle 
pressure, and the eye should be washed clear of them by a 2-per-cent. 
solution of boric acid in distilled water. If an astringent lotion is 
desired, sulphate of zinc can be added in the proportion of 2 grains 
to the ounce of the solution. The manipulation and medication are 
effected in the following manner: The surgeon's finger is made to 
exert pressure on the sac from below and toward the eye, while the 
patient's head is tilted backward and toward the opposite side. After 
the sac is emptied of secretions the boric solution- is made to rest in a 



RELATED DISEASES OF THE EYE AND NOSE. 125 

little pool over the eanaliculi while the sac is emptied as before, with 
the result that the solution enters the evacuated sac and medicates 
the nasal duct. This simple treatment, combined with proper meas- 
ures addressed to the nasal disease, will cure a large proportion of these 
cases. 

When this method proves ineffectual, the orifice of the canaliculus 
(Fig. 67) must be enlarged. This can be done with the iris-scissors 
or the lacrymal knife (Fig. 69), which is introduced with the sharp 
edge directed toward the eye, cutting the punctum open perpendicu- 
larly toward the palpebral fold for a distance of about one-sixteenth of 
an inch (two millimetres) or more. The lower canaliculus is the one 
that is generally opened. Then the solutions just mentioned, or silver 
nitrate, 2 to 5 grains to the ounce of water, should be used until 
either a cure is effected or it is demonstrated that there is a stricture 
of the duct. In the latter case the smaller probes of Bowman may be 
gently employed to dilate the stricture. For further surgical treatment 
the reader is referred to works on the eye. 



CHAPTEE X. 

DISEASES OF THE NASO-PHARYNX. 

Nasopharyngeal Catarrh. 

Synonyms. — Post-nasal catarrh; rhino-pharyngitis; retronasal 
catarrh; follicular naso-pharyngeal catarrh. 

Pathology. — Naso-pharyngeal inflammation may be acute or 
chronic, but the acute stage merges in the chronic form, leaving a 
thickening of the mucous membrane, — a proliferation of tissue that 
gives rise to a roughened and granular appearance of the membrane 
and increased secretion from the mucous glands. This is the condi- 
tion most often encountered, but the dry form is not uncommon. 

Etiology. — Sudden and extreme changes in meteorological condi- 
tions, especially in a low, damp climate, are undoubtedly the chief 
exciting causes of this disease. Inhaled dust is another important 
etiological factor; but climatic conditions are of prime importance; 
otherwise, those who live in a dusty atmosphere, but in a warm, high, 
dry, equable climate, would suffer equally with those under the reverse 
conditions. 

This disease is most common in the region of the Great Lakes 
and, indeed, in many other parts of America. Even in Colorado, the 
Mecca of consumptives, this disease prevails. But the soil favors this, 
for it is so light and sandy that the rains percolate through into the 
subsoil in a few hours, leaving on the surface a fine coat of dry dust, 
the toy of the winds and the torment of catarrh. In the Mississippi 
Valley and the Great Lakes Eegion the barometrical and thermomet- 
rical changes are rapid and excessive. The thermometer often falls 
thirty degrees or more in a few hours, and half that much in as many 
minutes. In hot summer-days, with southerly winds, cold waves sweep 
down from the northwest, catching the people in thin clothing, chill- 
ing the skin, and causing internal congestions that naturally attack 
the respiratory passages. The dampness of the atmosphere and the 
prevalence of dust aid in locating the seat of irritation in the most 
exposed air-cavities. After these sudden attacks of cold waves an 
influx of patients usually attests the cold-giving nature of the changes. 
(136) 






NASOPHARYNGEAL CATARRH. 127 

I have found San Francisco no better than Chicago in climatic con- 
ditions. The fogs of the early morning and the cold, penetrating 
winds of the afternoon, with only a few hours of congenial warmth 
to lure one to don warm-weather attire, present the conditions favor- 
able to the production of naso-pharyngeal catarrh. But the reverse 
of this picture is to be found by a twenty-minute ride across the bay 
to OaMand. There one may doff his overcoat and bask in the balmy 
sunshine of summer, while his neighbors a few miles distant shiver 
in the ocean-winds. But even here we cannot escape the irritating 
dust that plays hide-and-seek with the cilia of the nose. For catarrhal 
patients the climate of Los Angeles or San Diego is preferable to that 
of San Francisco; but even in these delightful gardens of America 
there is no escape from dust. 

The part played by this irritant in the causation of post-nasal 
catarrh is easily understood when we consider the conformation, posi- 
tion, and lining of the naso-pharyngeal cavity. Its shape is such as 
to receive and change the course of the current of air as it strikes 
the vault and posterior wall of the pharynx, and all the dust-laden 
air inhaled through the nose must come in contact with this part. 
The foreign particles not removed by previously impinging on the 
nasal cilia or membrane find lodgment here, and, if sufficient moisture 
has not been absorbed by contact with the nasal chambers proper, 
the secretions of the pharyngeal membrane are taxed to perform this 
function. The resulting storage of dust and the drying of the mem- 
brane, which is devoid of the acute sensibility characteristic of the 
nose and larynx, and therefore lacks prompt reflex efforts at dislodg- 
ment, tend to excite irritation and consequent inflammation. Other 
predisposing causes of naso-pharyngeal catarrh are discussed in the 
chapter on "General Consideration of Ear, Nose, and Throat Dis- 
eases." 

This disease, like hay fever, is undoubtedly more prevalent in 
America than in European countries. The reasons assigned for its 
prevalence in various parts of this country are sufficient to account 
for this difference. It is not a contagious affection, like epidemic 
influenza, neither can it be termed hereditary, but its universal pres- 
ence is certainly suggestive of a predisposing hereditary influence. 
It is not limited to the frail, but is just as likely to be encountered 
in the robust, and especially in the uric-acid diathesis. 

Symptomatology. — In the early history of naso-pharyngeal ca- 
tarrh the patient notices a sense of irritation in the upper and back 



128 



NASO-PHARYNGEAL CATARRH. 



part of the throat. This provokes attempts at clearing the throat 
or hawking which is irksome to the patient and disagreeahle to his 
companions. A sense of constriction and a tired or aching feeling 
is often present, especially while speaking in public. The vocal 
organs weary easily, and the necessary efforts to clear the throat dur- 
ing a lecture or sermon are wearisome to both speaker and audience. 
Clergymen are frequent subjects of this complaint. There is almost 
a universal habit among them of efforts to relieve this irritable condi- 
tion of the throat. 

Posterior rhinoscopy often discloses a thick, tenacious, light- 
yellow secretion sticking to the posterior wall of the pharynx. On 
removing this discharge the membrane appears very red and rough 1 
ened by the formation of granulations. These are round and punc- 
tated or irregular and flat, with broad bases suggestive of particles 
of a filled sponge. Frequently they coalesce, especially at the sides 
of the throat just behind and below the posterior faucial pillars, 
and form a welt extending upward and outward in the direction of 
the Eustachian orifices. These point to the "throat deafness" so often 
met with in catarrhal climates. The blood-vessels are often engorged 
and tortuous and stand out prominently above the surface of the sur- 
rounding tissues. The Eustachian prominences are swelled and red- 
dened and the orifices constricted or closed. Extension of the inflam- 
mation a little farther through the Eustachian openings results in 
tubal catarrh, or salpingitis, and impaired hearing, as already described 
in the ear division. The pharyngeal, or Luschka's, tonsil is sometimes 
hypertrophied, and in children adenoid vegetations may so occlude 
the vault of the pharynx as to preclude nasal respiration (Plate I). 
Mouth-breathing and its train of evil consequences result. The faucial 
pillars are more or less involved, presenting a swelled, infiltrated con- 
dition. 

Diagnosis. — There is little likelihood of confounding this affec- 
tion with any other. Adenoid vegetations are confined to the young 
and are easily seen with the rhinoscopic mirror or felt by the finger. 
The same may be said concerning pol} r pi. Syphilis causes sore throat, 
but the characteristic erosions and the history, added to the testimony 
of antisyphilitic remedies, serve to dispel any doubt. 

Prognosis. — Although it is the practice of charlatans to repre- 
sent this disease as being dangerous to life and leading to pulmonary 
consumption, its early history does not confirm such statements. In 
its early stage it yields readily to proper treatment, but after it has 



NASOPHARYNGEAL CATARRH. 129 

existed for a number of years it becomes persistently chronic and 
yields only to the most thorough methods of treatment. However, 
much relief can be afforded by hygienic measures, combined with 
proper cleansing and stimulating topical applications and surgical 
treatment. 

Treatment. — The first object of treatment is perfect cleanliness; 
detergents — such as De-bell's and Seller's solutions — should be used 
in the form of sprays, both through the anterior nares and throat, 
to dislodge all secretions and crusts that adhere to the nasopharyn- 
geal walls. If these alkaline, antiseptic sprays, that dissolve the 
tenacious secretions and dislodge them in ordinary cases, are not 
sufficient to remove them iu this form of catarrh, cotton, twisted upon 
a curved post-nasal cotton-carrier should be used to wipe out all the 
discharges. Then stimulating and tonic sprays should be applied with 
the Davidson or De Vilbiss atomizers. Camphor-menthol in ben- 
zoinol, 5-per-cent. coarse spray, or a 10-per-cent. solution in the form 
of a nebula, in the hand-vaporizer (Fig. 125) will afford decided relief. 
A tonic, antiseptic spray is had in eucalyptus in lavolin, 4 per cent.; 
or, as a tonic nebula to be used in the hand-vaporizer, an excellent 
preparation consists of oil of cubebs, 50 parts; pure camphor-menthol, 
10 parts; and lavolin, 40 parts. However, the latter solution must 
not be used in the form of a coarse spray. This and a 10-per-cent. 
solution of camphor-menthol inhaled through the throat and exhaled 
through the nose act as decided stimulants and tonics. It is my 
practice to prescribe for home treatment a 3-per-cent. solution of 
camphor-menthol in lavolin, to be used every morning and night. 
The patient is instructed to throw a sufficient spray of this prepara- 
tion into both nostrils and throat to satisfy him that the parts are 
entirely covered with the medicine. The application of this remedy 
proves very grateful and refreshing, especially to public speakers. 
Upon being used at bedtime it remains in contact with the mucous 
membrane during the hours of repose, when no efforts are made to 
clear the nose; so that its action is continuous over a number of 
consecutive hours. All hypertrophied tissues should be destroyed with 
the electrocautery. 

Excessive tobacco-smoking must be interdicted, and those who 
continue to smoke must be instructed that the habit of forcing smoke 
outward through the nose acts as an irritant and aggravates the ex- 
isting condition. The inhalation of dust; irritating gases, like those 
from matches, etc.; exposure to cold and damp and draughts of cold 



130 ATROPHIC CATARRH OF THE XASO-PHARYNX 

air, especially upon the back of the neck and back of the arms; and 
exposure of the feet to cold and wet must be avoided. Animal fibre 
must always be worn next to the skin. Wool is preferable to silk. 
Cotton and linen must not be used for underclothing. Consisting, as 
they do, of vegetable fibre, they favor rapid evaporation of the per- 
spiration, causing chilling of the skin and contraction of the capillary 
vessels and resulting internal congestion. The diet must be plain and 
nutritious, avoiding an excessive use of meats, sweets, wines, and beer. 

Atrophic Catarrh of the Naso-pharynx. 

This disease usually accompanies the same condition of the nose 
which has already been described, but it may exist independently 
of atrophic nasal catarrh. In the early stage of this affection the mu- 
cous membrane of the naso-pharyngeal space usually appears dry and 
shining. Later, crusts are formed similar to those described in ozaena. 
Sometimes quite large patches of these crusts, which adhere closely 
to the membrane and are removed with difficulty, are expelled. They 
are generally of a dirty-white or greenish color and sometimes brown 
or even black. The latter color is usually found where patients are 
exposed to the inhalation of a smoky atmosphere, in the neighbor- 
hood of factories, hotels, and buildings in which soft coal is largely 
in use. These crusts sometimes are removed with so great difficulty 
that the patient frequently is under the necessity of inserting his 
finger into the vault of the pharynx and detaching them with his 
finger-nail. 

The pathology and etiology of this disease are the same as for 
nasal ozaena, to which the reader is referred. 

The symptoms consist of a sensation of dryness in the throat, 
which is much more disagreeable than the presence of an hyper- 
secretion. When crusts form, decomposition takes place, imparting 
a foul odor to the breath. The efforts of the patient at dislodgment 
of these secretions cause gagging and sometimes vomiting, and for this 
reason they produce gastric disturbances. 

The points of diagnosis are identical with those given for ozama 
under the heading of "Atrophic Nasal Catarrh." 

The prognosis is unfavorable. This is a persistent, chronic dis- 
ease which is not easily amenable to treatment. However, much re- 
lief may be afforded until such time as the processes of nutrition can 
be so improved as to give permanent relief. 



FIBROUS TUMORS OF THE NASO-PHARYNX. 131 

Treatment. — Hydrozone and antiseptic detergent solutions — such 
as Dob ell's and Seller's — must be used abundantly to dissolve and dis- 
lodge the crusts. When no crusts are present, but there is merely a 
pale, dry, shining, mucous membrane, remedies that stimulate the 
muciparous follicles to secretion must be used. These consist of the 
eucalyptol, iodine, and cubeb sprays already mentioned. Further 
treatment for this affection is the same as that laid down for nasal 
ozama. 

Fibrous Tumors of the Naso-pharynx. 

Fibrous tumors in this locality are of infrequent occurrence 
(Plates II and IV). They are rarely found above the twenty-fifth year 
and occur more frequently in males than in females. They cause ob- 
struction to nasal respiration, dyspnoea, epistaxis, and facial disfigure- 
ment. 

Pathology. — These tumors occur singly and are attached by a 
broad pedicle to the roof of the pharynx. They are dense, smooth, 
and of a dark-red color. The blood-vessels of the interior are smaller 
than those of the mucous membrane covering them. Bleeding takes 
place easily; so that palpation with the probe causes a sanious dis- 
charge. These growths may develop to such an extent as to invade 
the throat even to a level with the epiglottis. 

A fibroma is a representative tumor of the mesoblastic type. Like 
the submucous tissue from which it takes its origin, it is a connective- 
tissue growth, and is the offspring of a highly vascular area. It is 
made up of mature fibrous tissue from a matrix of fibroblasts. The 
growth of this neoplasm is always slow, and there is sometimes a ten- 
dency toward a myxomatous degeneration, or it may undergo a transi- 
tion into a sarcoma. 

Etiology. — Their cause remains in obscurity. 

Symptomatology. — The most prominent symptoms are difficult 
breathing in consequence of the nasal obstruction, nose-bleeding, 
stupidity, a nasal intonation of the voice, and difficulty in articula- 
tion of speech. Pressure upon the orifices of the Eustachian tubes 
may cause obstruction to the ventilation of the middle ears, Eusta- 
chian salpingitis, and consequent deafness. When these growths 
assume large proportions they make sufficient pressure upon the sur- 
rounding structures to broaden the base of the nose and increase the 
width between the eyes, giving the appearance suggestive of the "frog- 
face" (Fig. 71). Pressure may be sufficient to cause separation of the 



132 FIBROUS TUMORS OF THE NASO-PHARTNX. 

nasal bones and absorption of the facial and cranial bones, producing 
intracranial complications. There is generally a copious muco-puru- 
lent discharge and difficult deglutition. 

Diagnosis. — These tumors are differentiated from mucous polypi 
by their hardness, frequent bleeding, and their occurrence only under 
the twenty-fifth year. They are distinguished from adenoid vegeta- 
tions in the vault of the pharynx by the soft, spongy, lobulated ap- 
pearance of the latter and their occurrence only in the very young. 
The appearance of the two in the rhinoscopic mirror and the sensa- 
tions imparted to the finger introduced into the naso-pharyngeal space 
render a differential diagnosis not difficult. 

Prognosis. — Fibrous polypi pursue a steady growth until, in 
from three to five years, they prove fatal. If their development can 
be repressed by local treatment until the patient arrives at the age of 
twenty-five years, the prospects of recovery are improved. But one 
should bear in mind Virchow's saying that "a fibroma only needs an 
increase in the size of its cells and a diminution of the cement-sub- 
stance to change it into a sarcoma." Such a growth located in the 
pharynx is subjected to a large amount of irritation, which favors a 
degenerative transition into a sarcoma. 

Treatment. — These growths should be removed with the galvano- 
cautery snare, electrolysis, ecraseur, powerful cutting forceps, or a 
curette. Before the operation for removal is commenced the body of 
the growth should be secured by a strong thread so as to prevent its 
dropping into the throat and producing suffocation. Curative results 
have been claimed by several writers from injections of alcohol, caustic 
potash, chloride of zinc, dilute acetic acid, or hydrochloric acid, etc., 
into new growths. For a further consideration of this subject see 
"Treatment" of "Cancer of the Pharynx." 

Electrolysis is especially indicated for growths having a sessile 
formation, which precludes the use of torsion or the snare. For this 
purpose a strong current is employed under general anaesthesia. Much 
has been claimed for the method of introducing medicaments with the 
electric current, or cataphoresis, but, whenever it is practicable to re- 
move the tumor in its entirety, it should be done. 

Operations of several kinds are practicable according to the size 
and the situation of any given growth. The old method of removal 
by the cold-wire snare is in quite general use, but on account of the 
great vascularity of these tumors and the consequent operative haemor- 
rhage, the electric snare recommends itself, since it sears over the 



FIBROMUCOUS POLYPI OF THE NASOPHARYNX. 133 

tissues and closes the mouths of the blood-vessels with coagula as the 
tissues are being severed. For the same reason, in those cases in which 
the form and position of the attachments of these neoplasms lend 
themselves to such a procedure, the use of the electric knife at a white 
heat is advantageous. Torsion can be practiced when the tumor is 
distinctly pedunculated. 

Certain cases of fibromata can be operated on through the natural 
oral or nasal channels. Others, either on account of peculiarities of 
attachment or excessive or irregular development, must be removed 
through the soft or hard palate, or by means of resecting the nasal 
bones or the superior maxilla. Sufficient room for operating may be 
obtained hj dividing the nose along the side of the septum, beginning 
at the nasal process and cutting from within outward. If more room 
is required, the nasal process is resected, and still better access is af- 
forded by incising the upper lip in the middle line and separating its 
attachments liberally. The tumor is then detached by one of the 
methods already mentioned, or by the periosteal elevator, or by blunt- 
pointed scissors, when it is drawn out with strong forceps. These are 
very bloody and dangerous operations and may require a preliminary 
tracheotomy and ligation of the common carotid artery. Special op- 
erations have been devised by Konig, Dieffenbach, Langenbeck, Eouge, 
Oilier, Kocher, and others. After removal, the attachment of the 
pedicle should be thoroughly cauterized. 

Fibromucous Polypi of the Naso-pharynx. 

These tumors are of somewhat rare occurrence, They vary in 
size from one to three inches (two to eight centimetres). They are 
smooth, oval, and of a dusky-red color and occasion nasal obstruction 
and deafness, but no haemorrhage. One serious inconvenience occa- 
sioned by them is the inability to blow the nose. 

Pathology. — .Unlike the fibrous growth, which occurs on the 
under surface of the basilar process, the fibromucous polypi, springing 
from the connective-tissue fibres and mucous elements, naturally par- 
take of their character. They are dissimilar to the fibrous polypi; 
are adenoid in appearance, texture, and history; and they do not tend 
to recur after extirpation. 

Treatment. — Evulsion should be made with strong forceps 
through the mouth, or the cold-wire or galvanocautery snare can be 
used through the nose. After their removal the site of attachment 
should be cauterized. 



134 adenoid growths in the vault of the pharynx. 

Malignant Tumors of the Naso-pharynx. 

These tumors are of very rare occurrence. They are attended 
with pain in the throat and back part of the nose, extending to the 
ear; catarrhal symptoms, with increased discharges from the nose 
and throat; difficulty in swallowing; and, as they progress, general 
impaired nutrition. They are likely to be of the sarcomatous type, 
either pear-shaped or lobulated (see "Sarcoma" of the pharynx, page 
239). Their growth is rapid, and there is a strong tendency to re- 
currence after their removal. Only a microscopical examination will 
reveal their true nature. They are likely to be mistaken for fibrous 
polypi, but are less dense, softer to the touch, and present quite a dif- 
ferent history. 

The prognosis is hopeless. 

Treatment consists in their removal, if possible, with the means 
already detailed for operations upon fibrous tumors. Supportive and 
tonic remedies should constitute a part of the treatment. (See "Car- 
cinoma of the Pharynx," page 232.) 



Adenoid Vegetations in the Vault or the Pharynx. 

Synonyms. — Hypertrophy of the pharyngeal, or Luschka's, tonsil. 

Pathology. — These growths occur in two varieties. The first con- 
sists of spongy, stalactite projections from the vault of the pharynx; 
the second of smooth, fibrous tumors of irregular shape. They are 
very vascular and contain lymph-cells and a follicular structure re- 
sembling that of the oral tonsils. 

The relation of adenoid growths to deaf-mutism has been made 
the subject of investigation by Frankenberg [American Medico- Sur- 
gical Bulletin, December 10, 1897). He examined 158 inmates of the 
deaf-mute institute in Prague. Including adenoids only that were 
large enough to fill the naso-pharyngeal cavity, there were 59 per cent, 
with these growths. Out of the 94 cases, there were 56 boys and 38 
girls. The particular pathological conditions of the ears in these 
subjects can be found under the heading "Deaf-mutism," page 520. 
Among 426 cases of adenoids Arslan found 6 deaf-mutes. He cured 
one and relieved another of these, both as to speech and hearing, by 
removing the adenoid growths (Plate I). 

The superior maxillary bone often presents a contracted appear- 
ance; the roof of the mouth is narrow and is highly arched, convey- 
ing the impression that the conformation of the roof of the mouth 



ADENOID GROWTHS IN" THE VAULT OF THE PHARYNX. 



135 



has resulted from the necessities of constant month-breathing, en- 
larging the cavity of the mouth at the expense of the nasal fossae 
(Fig. 70). 

Etiology. — This is usually a disease of childhood and is oftenest 
seen under the tenth year. Heredity is an important factor. Oft- 
times several children in the same family are subject to these growths. 
They are always to be looked for in children with hypertrophic rhi- 
nitis, enlarged f aucial tonsils, and high-arched or cleft palates. 

Symptomatology. — The most striking features in a pronounced 
type of this affection are the parted lips, prominent eyeballs, oblitera- 




Fig. 70. — Contracted Upper Jaw; Narrow Roof of Mouth with very 
High Arch, Encroaching upon the Nasal Fossae; Found in Habitual 
Mouth-breathers who have Adenoid Vegetations in the Vault of the 
Pharynx. Hypertrophied turbinals and oral tonsils are often associated 
with these conditions. 



tion of the normal lines of expression of the face, and a consequent 
appearance of listlessness and inferiority (Fig. 71). Mouth-breath- 
ing, a noisy respiration, snoring, and a lack of resonance of the voice 
are the typical symptoms. There is a characteristic thickness of 
speech, and nasal intonation. As Chaucer said, "He intones in his 
nose." Such children are absent-minded and have the appearance of 
being inattentive, which may be due to mental dullness or impaired 
hearing, or both. There are inability to fix the attention, or aprosexia 
(Rumbold), and defective memory. There is a plentiful, tenacious 
discharge of a grayish or bloody color. Examination with the finger 
causes bleeding. The history is one of recurring colds in the head, 



136 ADENOID GROWTHS IN THE VAULT OF THE PHARYNX. 

earache, diminished hearing, noises in the ears, or otorrhcea. There 
may be pressure on the Eustachian tube or an extension of the ade- 
noid inflammation through the Eustachian tube to the ear. The 
growths are light pink, turning to red on being irritated. They ob- 
struct posterior rhinoscopy, and are often unequally developed on the 
two sides. The symptoms given are of typical cases; in many they are 
not so well defined. 

We have sometimes been able, by anterior rhinoscopy, to observe 
the growths through the nose, when the passageway was unobstructed. 
While writing this, such a case is under observation preparatory to 
an operation. Although there is great hypertrophy of the left in- 
ferior turbinal, producing stenosis, the right fossa is so capacious as 
to admit of an excellent view of enormous adenoid growths. While 
the patient counts aloud to 30 or 40, the growths can be seen moving 
freely with the enunciation of the various numbers. In this case, a 
boy of 15 years, examination with the throat-mirror is not difficult. 

Diagnosis. — The symptoms described render this a simple matter. 
The rhinoscope is not easily used in children, and we rely principally 
upon the digital examination, with the finger well protected. 

Prognosis. — The tendency is to absorption during early adoles- 
cence and to disappearance when adult age is reached. 

Treatment. — Notwithstanding the fact that, with the advent of 
adult life, adenoid growths in the vault of the pharynx tend to ab- 
sorption, there are most excellent reasons why it is for the patient's 
interest to be rid of them. Semon has formulated these reasons as 
follow: (1) the ever-threatening danger of ear complications; (2) 
the greater liability to, and seriousness of, infectious diseases, espe- 
cially scarlet fever and diphtheria; (3) the influence of the obstruc- 
tion on the general health, mental development, and the' formation of 
the face, results which may remain even if the glands themselves 
undergo atrophy. 

While it is the practice of some rhinologists to treat adenoids 
with washes, sprays, caustics, the galvanocautery, etc., for periods 
varying from four to fourteen months, I much- prefer the one painless 
operation, lasting but five minutes and insuring a radical cure. 

The instruments are sterilized by boiling for five minutes in a 
1-per-cent. solution of bicarbonate of sodium, and placed within easy 
reach. The mouth-gag (Eig. 72) is inserted between the molar teeth 
before the anaesthetic is administered, and is held carefully in place 
by an assistant until the operation is completed; otherwise it slips 



ADENOID GROWTHS IN THE VAULT OF THE PHARYNX. 



137 



out of place and allows the jaws to close, after which they are sep- 
arated with much difficulty. Sections of soft-rubber tubing should 
be slipped over the dental extremities of the gag to protect the teeth 
and prevent slipping. 

The preferable an aesthetic for this operation is ethyl-bromide 
(hydrobromic ether; monobromethane). It is dispensed in 1 (fluid) 




Fig. 71. — A Mouth-breather (17 years old). (Author's Case.) Ad- 
enoid vegetations in the vault of the pharynx; hypertrophied oral tonsils; 
bilateral nasal polypi; spreading of nasal bones, producing great breadth 
of nasal arch; protrusion and wide separation of eyeballs (frog-face); 
suppurative ethmoiditis requiring curettement ; and chronic suppuration 
of both middle ears. 



ounce tubes. Before administering it the patient should be calmed 
into a tranquil state of mind, for if there is great excitement the drug 
is not so efficacious. The patient is held in a sitting posture on an 
assistant's lap (Fig. 73), with his feet and arms gently, but firmly, 
pinioned. An ounce of the bromide of ethyl is poured into the inhal- 



138 



ADEX0ID GROWTHS IX THE VAULT OP THE PHARYNX. 



ing-cone or mask and given in the same manner as in etherization, 
allowing a minimum of air to enter. Anaesthesia is induced in about 
one minute and lasts about five minutes. Probably not more than 
half an ounce of the anaesthetic is taken, but the remainder will not 
keep for subsequent use on another day and must be thrown away. 

Fessler gives excellent, practical suggestions regarding the use of 
ethyl-bromide: The preparation must be pure and fresh. The con- 
tents of a bottle must be used up the same day that the bottle is 
opened or else thrown away. Preparations that have been exposed to 
bright light or to air should not be used. For this reason, also, the 
cloths or flannel masks which have once been employed in producing 
the narcosis should not be used again before having been thoroughly 
cleansed and aired. 

A good device for administering the anaesthetic can be improvised 
by wrapping a thick towel into the form of a cone and tying a strong 




Fig. 72. — Denhart's Mouth-gag. 

cord about its apex to render it the more air-tight, or it can be folded 
into a box shape and pinned with safety pins. Into this inhaler 
should be placed sufficient clean cotton to absorb the fluid. When 
an Esmarch mask is used for narcosis with bromide of ethyl the 
flannel should be double the usual thickness, and folded in two layers. 
As soon as the patient is quieted by the means usually employed 
by anaesthetizers and hypnotizers he is directed to draw a long, deep 
breath, to breathe quietly; then the inhaler, into which the anaes- 
thetic has just been poured, is held closely over his nose and mouth. 
A slight extension of the extremities will be noticed to follow after a 
few inspirations, and the breathing usually continues deep and quiet. 
Complete anaesthesia is attained as soon as this extension begins to 
disappear, and at this instant is the time to operate rapidly, for sensi- 
bility returns again in a few minutes. We may prolong the narcosis 
for a few minutes, only, by adding another ounce (30 grammes) of 



ADENOID GROWTHS IN THE VAULT OF THE PHARYNX. 139 

the bromide of ethyl to the inhaler. The patient quickly recovers 
consciousness, and after lying down for half an hour or more he is 
ready to he taken home. 

The instant anaesthesia is complete Gottstein's large or small 
ring-curette (Fig. 74) is inserted behind the velum palati and upward 
near the vomer to engage the central, highest mass first. Then the 
cutting-surface is passed backward and downward in contact with the 
posterior pharyngeal wall as far as the growths extend. The same 




Fig. 73. — Position of Child for Adenoid Operation or Intubation; 
Mouth-gag Introduced. 

movement is executed on either side wherever there are growths, 
sweeping them all out by three or four passes of the curette. Finally 
the finger is inserted to discover if any remain. If so, they may be 
detached with the finger-nail or the curette. J. E. Schadle operates 
by means of the finger-nail trimmed to a point and hardened by im- 
mersion for a few minutes in alcohol. (The Laryngoscope, July, 1896.) 
As soon as all the adenoid tissue is extirpated, the gag is removed 
and the patient's body is inclined quickly forward, with the face 



140 ADEXOID GROWTHS IN THE VAULT OF THE PHARYXX. 

downward. The surgeon loudly commands the patient to "spit it 
out!" Hence the blood escapes through the nose and mouth and the 
patient at once begins efforts at expulsion, and the blood is thereby 
prevented from entering the larynx or the stomach. 

If the faucial tonsils are hypertrophied, they are removed before 
the adenoids. This order of operating presents two advantages: the 
space through which we operate is amplified and there is no bleeding 
from above to obscure the tonsillotomy. The operator must waste no 
time, but, if he act promptly and rapidly, there is sufficient time for 
all this procedure under the anaesthesia. 

Haemorrhage lasts but a few minutes and generally ceases by the 
time full consciousness is restored. This method deprives the opera- 
tion of the horrors experienced by children whose adenoids are ex- 
tirpated without anaesthesia; and neither children, nor parents who 
are excluded from the room until the bleeding ceases, retain any re- 
volting memories of the affair or their doctor. Many cases receive 




Fig. 74. — Gottstein's Ring-curette. 

no after-treatment; but it is better to give a spray of camphor-men- 
thol and benzoinol — 3 per cent. — with an atomizer (Fig. 1 1) for home 
use four times a day for a week or more. 

While instances of severe haemorrhage from this operation are 
reported, I have never witnessed any. C. H. Knight reported a case 
of death from haemorrhage following an operation for adenoids in a 
boy 4 years old. Death occurred two days after the operation. (The 
Laryngoscope, April, 1898.) 

James E. Newcomb had three cases of haemorrhage. One was a 
woman about 18 years old. Another was a girl of 13 years whose 
adenoids were removed under cocaine anaesthesia. Bleeding occurred 
forty-eight hours after the operation. In the third case, which was a 
fatal one, the patient was a boy of 4 years. Four hours after the 
operation haemorrhage set in, and terminated fatally on the morning 
following the operation. The two other cases recovered. On looking 
up the subject 16 cases of haemorrhage were found following ade- 
noidectomy, with 2 deaths. 



ADENOID GROWTHS IN THE VAULT OF THE PHARYNX. 141 

Hooper reported a case of death following a digital examination. 

Among 11 cases of these haemorrhages 4 occurred in patients 
under 10 years of age, 5 were between 10 and 20 years of age, and 
1 was 28 years old. Chloroform was used in 3 cases, and cocaine in 
the same number. Various instruments, as well as the finger-nails, 
were employed. Generally the haemorrhage takes place immediately 
after operating, but it has occurred as late as 24 and 48 hours after- 
ward. 

Delavan has reported a fatal case in a child of 4 years, and 3 
other cases whose ages are not given. In Delavan's case there was a 
bleeding diathesis. 

Newcomb mentions "a case of a boy 2 1 / 2 years old who had 
adenoids removed with the finger and forceps, under ether. Haemor- 
rhage occurred 8 hours afterward, and death in 24 hours." 

Van der Poel reports 2 cases of profuse bleeding in his practice. 
The first, a girl of 8 years, was a case of haemophilia. She had suf- 
fered one year before from an alarming haemorrhage following the 
extraction of a tooth. The second was a boy of 14 years who was 
operated on without anaesthesia, and who had a mitral regurgitant 
murmur resulting from rheumatic endocarditis. Both cases recov- 
ered. In case of serious haemorrhage the vault of the pharynx should 
be thoroughly packed with cotton wet with a saturated solution of 
suprarenal extract, in the manner detailed in the section on epistaxis. 

In my experience with the operation none but satisfactory re- 
sults have obtained. One needs to take care not to wound the orifices 
of the Eustachian tubes or to drag a mass of the adenoid tissue down 
into the throat and leave it hanging there by the pharyngeal mem- 
brane intact. We have observed this condition after what must have 
been a hasty and incomplete operation. The finger should not be 
inserted into the pharyngeal vault while the curette is in action; but 
one should not fail to examine immediately after curetting to ascer- 
tain if the adventitious tissue has been completely removed. We have 
never observed any bad effects from ethyl-bromide. It is as safe as 
ether and far preferable for such short operations. 

The operation is not formidable if skillfully performed. It 
should be a thorough curettement, and the cavity is not difficult of 
access, providing that the mouth is kept properly gagged. In a large 
number of operations by my assistants and myself with bromide-of- 
ethyl anaesthesia no accident or haemorrhage of importance has oc- 
curred. 



142 



ADENOID GROWTHS IN THE VAULT OF THE PHARYNX. 



Keferring to the operation under this anaesthetic, T. Melville 
LTardie says: — 

"The advantages of the drug are : — 

"1. The laryngeal reflex very probably persists, and any blood or 
tissue entering the larynx is promptly expelled. 

"2. The sitting posture of the patient, possible in the exhibition 
of this anaesthetic, is the most convenient one for operating upon 
tonsils and adenoid growths, and makes easy the passage of blood 
from the nose and mouth; little of it is, as a rule, swallowed. 

"3. Nausea and vomiting are rare, and the patient generally ex- 
periences but little discomfort after the operation. 

"The disadvantages of the anaesthetic are: — 

"1. It is not perfectly safe, four or five deaths having been re- 
ported. 

"2. The time of anaesthesia is not always long enough to permit 
of thorough operation. In my experience this is not usual, but it 
cannot, on the other hand, be called very infrequent. 

"3. The anaesthetic is not always well taken." 

Witzel, who reports 465 anaesthesias, and who believes it to be 
the least dangerous anaesthetic, tabulates the following unpleasant 
effects occurring in 28 cases: — 

"(a ) Great excitation in 9 cases, in 4 with much sweating. 

"(b) Cyanosis in 2 students somewhat the worse for liquor. 

"(c) Asphyxia, but rarely with his method: first a few drops, 
then the whole quantity of the anaesthetic. 

"(d) Malaise, lassitude, vomiting. 

"(e) Urination in 3 cases. 

"(f) Great sexual excitement. 

"(g) In 2 cases he could not produce anaesthesia with 1 and 2 



ounces/ 



Conclusions. 



1. Adenoid vegetations should be removed under general anaes- 
thesia in the great majority of young children. 

2. The cold-wire snare and cocaine anaesthesia are satisfactory 
in older children and in adults, but cocaine should not be used in 
young children. 

3. Nitrous-oxide anaesthesia is frequently of too brief duration 
for the proper performance of this operation. 



ADENOID GROWTHS IN THE VAULT OF THE PHARYNX. 143 

4. Ethyl-bromide, apart from the question of its safeness, which 
is still undecided, is a desirable anaesthetic in many cases. 

5. Ethyl-bromide is not well taken, as a rule, by very nervous or 
frightened children. 

6. Ether should be substituted for bromide of ethyl when the 
operation is likely to be a lengthy one. 

7. The Gottstein curette is, all things considered, the most satis- 
factory single instrument, and particularly in bromide-of-ethyl opera- 
tions. 

Accidents Attending Adenoid Operations. 

"C. E. Holmes and H. S. Garlick contribute personal experiences 
in breaking Gottstein curettes when operating on adenoids. The 
former writer was fortunate enough to engage the fragment of the 
curette, consisting of the semicircular end of the instrument, with 
his finger and thus removing it from the child's naso-pharynx. The 
other patient swallowed the broken piece, which passed through the 
alimentary canal in three days without discomfort." ("American 
Year-book," 1902.) 



PART II. 



Diseases of the Pharynx. 



1,0 



(145) 



PLATE IV. 



PLATE IV 



Figure 1.- — The anterior nares are dilated by the nasal speculum, exposing the 
inferior turbinated bodies greatly hypertrophied; the head is inclined backward 

Figure 2.— Hypertrophy of the left inferior turbinated body; removal by 
means of the snare and transfixion-pin under cocaine or eucaine anaesthesia. 

Figure 3. — Posterior rhinoscopic image, normal appearance. 

1. Nasal septum,, or vomer. 6. Fossa of Rosenmiiller. 

2. Superior turbinated body. 7. Inferior turbinated body. 

3. Superior meatus. 8. Velum palati and uvula. 

4. Middle turbinated body. 9. Nasal passages between the septum 

5. Orifice of the Eustachian tube. and turbinated bodies. 

Figure 4. — Posterior rhinoscopic image showing a posterior hypertrophy of the 
left inferior turbinated body. 

Figure 5. — Posterior rhinoscopic appearance of a case of hypertrophic rhinitis 
showing: — 

1. Superior turbinated body. 5. Hypertrophies of the posterior ex- 

2. Middle turbinated body. tremities of the right middle tur- 

3. Hypertrophy and great thickening binated body and of the left in- 

of the septum. ferior turbinal. 

4. Orifice of the Eustachian tube. 



Figure 6. — Pharyngoscopy. 

1. Soft palate. 

2. Uvula. 

3. Anterior pillar of the fauces. 

4. Posterior pillar of the fauces. 



5. Oral tonsil. 

6. Posterior wall of the pharynx. 

7. Retropharyngeal abscess. 



Figure 7. 
pharynx. 



-Pharyngoscopy, revealing a fibromucous polypus of the naso- 



Figure 8. — Laryngoscopy, showing the image of the larynx in the laryngo- 
scopic mirror. The vocal cords are widely separated as seen during a deep inspira- 
tion. Below the white vocal cords four rings of the trachea are visible. The handle 
of the mirror and the towel on the tongue are cut off. 



Figure 9. — The larynx during forcible 

1. Inferior surface of the epiglottis. 

2. Anterior commissure of the vocal 

cords. 

3. Cushion of the epiglottis. 

4. Superior glosso-epiglottic fold. 

5. Lateral glosso-epiglottic fold. 

6. Cricoid cartilage. 

7. Ventricular band. 

8. Ventricle of Morgagni. 

9. Trachea. 



inspiration. 

10. Left bronchus. 

11. Literary tenoid fold. 

12. Right bronchu>. 

13. Cartilage of Santorini. 

14. Cartilage of AYrisberg. 

15. Aryepiglottic fold. 

16. 1 1 void fossa. 

17. Right vocal cord. 

18. Pharyngo-epiglottic fold. 

19. Superior surface of the epiglottis. 



FLUTE III, 




CHAPTER XI. 
DISEASES OF THE PHARYNX. 

Acute Pharyngitis, or Simple Sore Throat. 

Pathology. — Acute sore throat may be characterized by a simple 
hyperemia or an active inflammation with round-cell infiltration of 
the mucous membrane of the pharynx and serous effusion in the sub- 
mucous tissues. The secretions contain epithelial cells, pus-corpus- 
cles, and micrococci. 

Etiology. — There is quite a wide divergence of opinion respect- 
ing the causes of acute catarrhal inflammation of the throat. There 
are excellent observers who deny the classical theories of taking, or 
catching, cold. Thorner and Fick combat the idea. But what shall 
we say of the common experiences of life among laymen and doctors 
alike? When individuals possessed of unusual intelligence and 
powers of observation note that certain phenomena invariably follow 
given causes, that exposure of certain skin-surfaces, like the back of 
the neck, to cold draughts of air, is regularly and repeatedly followed 
closely by S3'mptoms of irritation or inflammation of the nasal or 
pharyngeal mucous membrane, not a few times only, but scores and 
hundreds of times in a long experience, shall we say that human testi- 
mony is not to be accepted, that the powers of observation are at fault, 
the reason clouded, and experience a delusion? Shall testimony of 
such a positive nature as would receive credence, and upon which a 
just verdict would be rendered in law, be not accredited equal weight 
in medicine? The logic of consecutive circumstances and events is 
no less forceful here than in other departments of physics. 

In the case of certain subjects the exposure of the back of the 
neck for a short time to cold winds is just as certain to be followed 
by a hyperemia or an actual inflammation of the nasal or pharyn- 
geal mucous membrane as the inhalation of the fumes of a lighted 
match by a person subject to attacks of hay fever will precipitate a 
paroxysm of that disease. Chilling the skin of the chest by exposure 
to cold winds causes a reflex paresis of the blood-vessels of the bronchi 
or lungs, resulting in hyperemia and congestion, or inflammation, of 

(147) 



148 



ACUTE PHARYNGITIS. 



the lining mucous membrane. The same condition of the correspond- 
ing membrane of the nose or throat is caused in certain sensitive or 
predisposed persons by the chilling of the feet or back of the head 
or neck, but not by the impression of cold on the nose or throat di- 
rectly. These causes and effects follow each other in such quick and 
logical succession, and are the subjects of such universal observation 
and experience, that one cannot ignore or resist their force. 

The theory that these diseases are the result of bacterial infec- 
tion may be, in some part, true, for such micro-organisms may easily 
enough act as exciting causes which cannot be resisted by a membrane 
already weakened by paresis of its vessels caused by the impression of 
cold; but cold is by no means held to be the only predisposing or 
exciting cause of acute catarrhal attacks. Streptococci and other 
germs have been found in the secretions in abundance, but their pre- 
cise relations to the disease, cause or product, have not been deter- 
mined. Acute pharyngitis occasionally follows an extensive or deep 
cauterization of the nasal tissues. 

This affection is an accompaniment or a sequel of the exan- 
themata, improper use of the voice, traumatic or chemical injuries of 
the throat, ioclism, etc. Predisposing causes are heredity, impairment 
of the digestive and eliminative functions, and living in overheated 
and ill-ventilated rooms. 

Symptomatology. — The first intimation given of an attack of 
acute pharyngitis is a sense of discomfort in the region of the throat 
and more or less stiffness of the muscles concerned in deglutition, or 
actual pain. The temperature rises in severe attacks, especially in 
children, several degrees, even as high as 103° or 105° F. In mild 
attacks there is no fever. The naso-pharynx is frequently involved 
and the symptoms are proportionately extended. There are likely to 
be headache and symptoms referable to the ear, such as a feeling of 
stuffiness, dullness of hearing, and ringing in the ears. Of course, 
these symptoms are attributable to an extension of the inflammation 
to the Eustachian orifices or tubes. It is not uncommon to see the 
middle ear involved to the extent of acute otitis and suppuration, with 
perforation of the membrana tympani. The act of swallowing causes 
pain, to avoid which the head and neck are made to perform certain 
movements characteristic of painful deglutition. The voice sounds 
muffled and obstructed and its use is avoided on account of the dis- 
comfort produced. During the act of swallowing the food is prone to 
enter the post-nasal space and occasion much discomfort. 



ACUTE PHARYNGITIS. 149 

After the dry stage of inflammation has passed, the throat be- 
comes bathed in a sticky mucus. This happens about the second day, 
and soon after this pus-corpuscles begin to make their appearance. 
The efforts to clear the throat of these rapidly accumulating dis- 
charges cause so much acute suffering that they are often swallowed, 
when nausea and vomiting are likely to follow. The breath becomes 
foul and the tongue thickly coated, indented, and flabby in severe 
attacks. 

Early inspection shows a bright-red color of the membrane cov- 
ering the fauces and pharynx. At first this is simply hypersemic, but 
as exudation of serum takes place there appears a swollen, cedematous 
condition, especially marked in the loose tissue of the soft palate and 
uvula. The velum is thickened and its movements are restricted 
and painful. The uvula is swelled to much more than its normal size; 
it is elongated and feels like a foreign body in the throat, exciting 
frequent attempts to swallow (Plate III, Fig. 8). 

The duration of this disease varies from two or three days to a 
week or longer. The high temperature of the initial stage drops 
in a day or two and remains nearly normal. It generally develops on 
examination that the patient has been subject to similar attacks, with 
a suggestiveness of periodicity. They are expected in the fall, winter, 
or spring, which points to the probability that there has been a pre- 
disposing chronic inflammation that requires treatment to avert fu- 
ture attacks. 

Diagnosis. — Simple sore throat cannot always be distinguished 
from the sore throats of measles and scarlet fever until the eruption 
appears, or from tonsillitis until the glands swell. In rheumatic sore 
throat there is not likely to be so marked an cedematous condition of 
the tissues, but more pain referable to the cervical muscles. 

Prognosis. — The disease lasts only about a week and is not dan- 
gerous unless it extends to the larynx. 

Treatment. — If seen during the first stage of the attack it can 
be averted or greatly ameliorated by the administration of atropia 
combined with morphia in the proportion of 1 / 40 o g ram °f atropia 
to 1 / 8 grain of morphia. Even in the second stage of inflammation, 
when serum and mucus are pouring forth in abundance, the siccative 
effect of these remedies lessens the secretion and the consequent 
painful efforts to swallow it, while their anodyne properties reduce 
the suffering to a minimum. The atropia antagonizes the nauseating, 
depressing, and constipating effects of the morphia. I have often 



150 ACUTE PHARYNGITIS. 

averted these attacks in patients who had been subject to sieges of 
this disease with such distressing regularity that their experience was 
not to be ignored. Instead of suffering for a week or more, the symp- 
toms would either disappear quietly in a few hours or cover a period 
of only a day or two, and with but little inconvenience. 

The use of quinine, which is so common among the laity as well 
as among physicians, leads to serious results in numerous instances. 
Some families buy quinine by the ounce and keep it in the medicine 
closet ready for daily doses for the slightest ills. Some of the most 
hopeless cases of deafness I have ever met are those occasioned by 
the use of quinine. It is less effective and more harmful than other 
remedies. At the onset of an attack the patient had better go to bed, 
if the symptoms are severe, and take the tablets mentioned contain- 
ing the atropia and morphia, or the coryza tablets, containing, each, 
caffeine, 1 / 6 grain; morphia, 1 / 12 grain; and atropia, V 600 grain. 
There is seldom any necessity for repeating these more than two or 
six times during the first two days, when the symptoms will often 
have disappeared. It frequently happens that one or two doses are 
sufficient. The effects of one dose last about four or six hours, when 
the patient is directed to take another, providing the symptoms begin 
to revive. He is never allowed to know the nature or the name of 
this remedy for fear of establishing a drug habit. 

The bowels should be opened with a saline draught or a laxative 
pill. A half drachm or more of sodium phosphate is effective. 

The old-fashioned sweats were quite effective, but after leaving 
the bed the skin is like a sensitive plant and every breath of cool air 
has a chilling effect, so that patients are left more liable to take cold 
after the sweat. Moreover, the excessive flow of perspiration is weak- 
ening. 

The air of the room should be kept moist during the dry stage 
of the first day or two, and steam-inhalations are grateful. These are 
best produced by utilizing some vessel having a nozzle (Fig. 22), that 
may be found at hand in every house, like the tea-pots, into which a 
pint of very hot water is poured. Tincture of benzoin, camphor, 10 
drops of pure camphor-menthol, or a few crystals of menthol aie 
added to the steaming water, a thick napkin is wrapped about the 
nozzle to protect the lips, which are to embrace the tip, and this 
medicated steam is inhaled into the throat. It must not be too 
strongly impregnated with the medicaments so as to produce an irri- 
tating effect. 



ACUTE PHARYNGITIS. 151 

When both the nose and throat are suffering from an attack of 
acute inflammation, we have found that menthol afforded relief, espe- 
cially during the dry stage, by employing it as follows : A few of the 
crystals are placed in a teaspoon or saucer and heated over a lamp or 
stove until the crystals melt and produce fumes that penetrate every 
part of the room. Just enough is used to medicate the atmosphere 
to the point of comfortable inhalation. The patient closes or covers 
his eyes to prevent any smarting of the conjunctivae, and is instructed 
to inhale through both his nose and mouth, if nasal respiration is 
possible. This causes a free flow of mucous secretion that bathes and 
moistens the inflamed membrane and greatly relieves the sense of 
burning heat and dryness. 

In order to obtain a continuous effect of ammonium chloride on 
the blood-vessels, and the soothing effect of Tolu and licorice, I have 
prescribed with satisfaction a tablet consisting of the following in- 
gredients, or their equivalents: — 

IJ Ammonii chloridi, . . . . . . gr. j. 

Tincturae opii camphoratae, 

Syrupi seillae compositi, 

Syrupi Tolutani, . . . .of each, m. v. 

Extracti glycyrrhizse, . . . . gr. iij. — M. 

This tablet is dissolved slowly in the mouth, and the resulting 
medicated saliva is kept in contact as much as possible with the in- 
flamed membrane. During the dry stage pilocarpine can be used, if 
it is desired to produce diaphoresis, 1 / 10 or 1 / 6 grain two or three 
times during the day, or enough to produce considerable perspiration. 
Gargles are not very efficient, since they reach only the anterior sur- 
face of the fauces and generally produce much discomfort. Potassium 
chlorate has been a very popular remedy for a long time, but I ha^e 
never been able to observe any beneficial effect from it, except that 
of a detergent in the form of a wash. The bromide of potash pro- 
duces more of a sensation of relief than the chlorate in solution, and 
if swallowed in 10- or 20-grain doses produces a sedative effect. 

The glycerite of tannin causes an exudation of serum and relieves 
the distended blood-vessels, besides contracting the vessels and thus 
modifying the intensity of the inflammation by a double effect; but 
the objection to its use is the necessarily disagreeable method of ap- 
plying it to the throat with a camel's hair pencil or cotton-applicator. 
It cannot be sprayed with an atomizer without heating it to an 
uncomfortable temperature. After using it in my private and dis- 



152 ACUTE PHARYNGITIS. 

pensary practice for many years I must say that it is an effective rem- 
edy if thoroughly and gently applied, notwithstanding the forcibly 
expressed disapproval of this remedy by so eminent an authority as 
Lennox Browne. By applying it several times a day the inflammation 
is subdued and the attack materially shortened. The author has used 
guaiacol in these cases, but has found different purchases to vary 
considerably in strength. Some specimens cause but little burning 
and smarting when applied pure, while others are very violent in 
their action and need to be diluted one-half. Patients feel relieved 
after the applications, particularly in case of high temperature. In 
some instances in which we used the pure guaiacol the membrane 
looked immediately after the application as if an escharotic had been 
used. It was covered with a light-gray pellicle, and on the following 
morning the mucous membrane of this area was broken down and 
ulcerated. There is the same objection to this that can be urged 
against any remedy that must be applied with a swab or probang. 

Cocaine for this disease is condemned. The effect is transitory, 
unless one takes into account the possible after-effects of a contracted 
drug habit. Thorner has experienced excellent results from salol in 
10- or 15-grain doses four to six times a day. It relieves the pain 
in both pharyngitis and tonsillitis. The writer has experienced similar 
results with this remedy and with salophen. The application of ice 
to the throat externally, which can be accomplished with an icebag 
(Fig. 194) and by sucking pieces of ice, if they can be relied upon as 
being free from disease germs, may modify and abbreviate the in- 
flammation. Antipyrin, acetanilid, phenacetin, salophen, and aconite 
are useful during the fever and painful stage. After a muco-purulent 
discharge has formed, the antiseptic sprays, followed by the soothing, 
oleaginous inhalents of salol, etc., are beneficial in cleansing, disin- 
fecting, and protecting the inflamed surfaces. (See Appendix.) 

The diet must consist of very nourishing fluids, like the animal 
broths, beef-tea, barley- and rice- water, milk, etc. The body should 
be clothed according to the principles laid down in treating of acute 
rhinitis. One should always dress as warmly as comports with com- 
fort. 

The strong tendency of this disease to extend to the Eustachian 
tubes and middle ears makes prompt and efficient treatment impera- 
tive. The most effective measures for preventing or managing these 
complications are dealt with in the divisions on "Eustachian Tubal 
Catarrh*' and "Acute Inflammation of the Middle Ear." 



simple chronic pharyngitis. 153 

Simple Chronic Pharyngitis. 

Synonyms. — Chronic sore throat; chronic catarrh of the throat. 

Pathology. — The condition here is essentially a repetition of the 
process that eventuates in simple chronic rhinitis. Frequently recur- 
ring attacks of congestion and inflammation cause a loss of tonus of 
the blood-vessels, which remain permanently dilated. Varicose veins 
stand out prominently in their tortuous courses, and the membrane 
remains thickened. The infiltrated tissues (Plate III) are deprived of 
the power of returning to their normal condition through the process 
of absorption because of the interruption to this process occasioned 
by repeated attacks. 

Etiology. — Generally, simple chronic pharyngitis is the sequel 
of acute attacks, but it may result from the abusive use of alcoholic 
beverages, excessive smoking, indigestion, and torpidity of the liver. 
Persons exposed to a smoky, dusty atmosphere or irritating gases are 
especially liable to this form of catarrh. A diseased condition of the 
nasal membrane predisposes to this affection. 

Symptomatology. — A sensation of stiffness or a parched feeling 
is experienced in the throat, which is only temporarily relieved by 
drinking. The voice is often lowered in pitch and becomes easily 
fatigued. Viscid masses of mucus are sometimes seen clinging to 
the posterior pharyngeal wall, and efforts to remove them result in 
explosive, scraping expulsions of the air that add to the existing 
trouble and set up irritation of the uvula and velum palati. These 
parts are thus forced into participation in the throat trouble and 
often are of a deep-red color and swollen and the uvula is elongated. 
The resulting contact of the uvula with the tongue aggravates the 
condition already present by provoking a cough and frequent swallow- 
ing occasioned by a feeling as if a foreign body were in the throat. 

Diagnosis. — The conditions already described render the diag- 
nosis a simple matter. It is not likely to be confounded with any 
other disease. 

Prognosis. — This affection is annoying, but not dangerous to life, 
and the prospect of relief is good if the patient is willing to submit 
to continuous treatment for a considerable time. 

Treatment. — After complete cleansing of the pharynx by the 
antiseptic solutions given in Chapter I, Sajous prefers silver-nitrate 
solution, 40 grains to the ounce. It reduces the calibre of the blood- 
vessels and promotes absorption. If silver is used, the strong is pref- 
erable to the weak solution. This is applied daily with cotton on a 



154 ACUTE RHEUMATIC PHARYNGITIS. 

holder, with care not to let it drip or press out into the larynx. The 
author has found that patients experience great relief by using at 
home — every morning and night at first, and later, when improvement 
is marked, only at bedtime — a 3-per-cent. solution of camphor-men- 
thol in benzoinol or lavolin. I have prescribed this for hundreds of 
patients, and they often say, many months afterward, that their im- 
provement was so great and gratifying that they have had the pre- 
scription repeatedly filled, and have obtained the remedy for their 
friends. This is used with a small hand-atomizer (Fig. 11). 

For office-treatment, after the cleansing throat-douche in coarse 
spray with sufficient air-pressure to dislodge and expel all the secre- 
tions that may stick to the membrane, we use, for a protective and 
emollient, benzoinol; for antiseptic and stimulant purposes, euca- 
lyptus in lavolin, 4 per cent., and pine-needle oil in the same pro- 
portion; and, if the membrane become too dry from insufficient 
secretion of mucus, 90 parts of oil of cubebs with 10 parts of pure 
camphor-menthol. This acts as a decided tonic. 

Pernicious habits must be stopped, and indigestion and torpidity 
of the liver overcome by proper treatment and hygiene on general 
principles. 

Acute Kheumatic Pharyngitis. 

Synonyms. — Kheumatic sore throat; rheumatic angina. 

Pathology. — The pathology of this affection is the same as in 
rheumatism, the discussion of which belongs to the province of gen- 
eral medical works. The uric-acid diathesis is discussed under the 
heading of "Hay Fever" (page 36). 

Etiology. — In persons who are subject to attacks of sore throat 
the acquirement of the rheumatic habit of body is likely to be fol- 
lowed by this type of throat affection. The attacks usually follow ex- 
posure to cold and damp. 

Symptomatology. — Attacks come on suddenly after the im- 
pression of cold, and announce their presence by pain in the throat 
and great difficulty in swallowing. The pain of deglutition is so acute 
that the patient refrains from eating or even quenching his thirst. 
All this time there appears to be an increased secretion and flow of 
saliva, which necessitates frequent spitting or the alternative of 
swallowing. This act keeps the sufferer constantly harassed, for the 
movements of the muscles of deglutition cause exquisite distress, and 
with each act the head and neck are seen to execute certain move- 



ACUTE EHEUMATIC PHARYNGITIS. 155 

ments characteristic of attempts to avert the inevitable painfullness 
of the act. While the attack lasts the suffering is greater than is 
usually experienced in simple acute pharyngitis, for the soreness in 
the rheumatic form is not confined to the mucous membrane of the 
pharynx alone, but exists in the muscles concerned in the movements 
of swallowing and even in the superficial muscles of the neck, such 
as the sterno-cleido-mastoid. 

These attacks may not last more than a day or two, when other 
parts, like the muscles of the back or the shoulders, may be attacked. 
On the other hand, there are patients who are not conscious of ever 
having had an attack of rheumatism, at least an acute attack, but who 
are subject to periodical visitations of the typical throat affection at 
certain seasons of the year, either at the change from winter to spring 
or in the late fall. 

The mucous membrane of the palate and pharyngeal wall ap- 
pears of an intense-red color and has a puffy, swelled look. There is 
sometimes headache, accompanied with fever of a mild grade. After 
a few attacks those who are subject to them readily recognize their 
character. 

Diagnosis. — The distinguishing features are the suddenness and 
severity of the attack, the exquisitely painful deglutition, the sore- 
ness of the cervical muscles, the brevity and shifting character of the 
disease, and the rheumatic history. 

Prognosis. — This disease is self-limited, so far as its manifesta- 
tions in the throat are concerned, for it passes off in about four days, 
but to return again on exposure. Prompt treatment will avert at- 
tacks. 

Treatment. — Salicylic acid in some form is the most effective 
remedy. The author prefers a freshly prepared salicylate of sodium, 
and generally prescribes it in the following formula: — 



1^ Acidi salicylici, 


. 


. 


3iij. 


Sodii bicarbonatis, 


. 


. 


3ij. 


Elixiris gaultheriae, 


. 


. 


3ss. 


Glycerini, 


. 




3iij. 


Aquae, .... 


. q. s. 


ad 


5iv. 



Misce. Signa: One teaspoonful, in water, every two or four hours. 

This is given every two hours, at first, until a perceptible im- 
provement is shown or until the physiological effects are manifested: 
ringing in the ears and slight impairment of hearing. Then the doses 
are stopped or diminished or placed sufficiently far apart to avoid 



156 CHRONIC RHEUMATIC SORE THROAT. 

these effects. The latter are similar to those of quinine, and must be 
avoided as far as possible, so as not to produce hyperemia or con- 
gestion of the middle ears or irritation of the auditory nerves. If 
the salicylate is not well borne, if gastric disturbance and head symp- 
toms indicate unusual susceptibility to this drug, salicin can be ad- 
vantageously substituted for it. This is best given in pilular form in 
doses of 5 grains, as detailed for the administration of the salicylate. 
In my opinion these preparations are preferable to the alkalies, 
guaiacum, or salol, although the latter and salophen, as well, produce 
excellent effects. 

For the fever and pain antipyrin affords the most decided relief. 
Indeed, this remedy appears to exercise a special influence in quelling 
this disease, and is superior to phenacetin, acetanilid, etc., not only 
in reducing temperature, but in transcending the limited action of 
an antipyretic. Potassium bromide, bromidia, or morphia combined 
with a proportionate amount of atropia, may be called for to subdue 
the pain. Effervescent citrate of lithia, soda, and potash and alka- 
iithia are indicated to rid the blood of uric acid and to prevent subse- 
quent attacks. 

As an external application, I have found the following liniment 
efficacious: — 

$ Olei tiglii, 3ij. 

Chloroformi, . . . ... . . 3ij. 

Aquae ammonii fortioris, Bj. 

Olei sesami, . . ., Siij- 

Misce. Signa: Apply on cotton. 

This is used by saturating a layer of lint or cotton, which is ap- 
plied to the whole anterior and lateral aspects of the neck and then 
covered with a thick layer of cotton. The underclothing should al- 
ways consist of wool. 

Chronic Eheumatic Sore Throat. 

Synonym. — Gouty sore throat. 

Pathology. — This has generally passed under the name of gouty 
sore throat and is due to the same causes that operate to produce 
various rheumatic or gouty manifestations in other organs. There 
is undoubtedly an increased formation and a retention of uric acid 
in the bod} r , and these processes, together with their resulting mor- 
bid phenomena, are discussed at length in the chapter on hay fever 
(page 3(J). 



CHRONIC RHEUMATIC SORE THROAT. 157 

Symptomatology. — This disease differs from acute rheumatic 
sore throat principally in degree. There is not acute suffering ex- 
cept in exacerbations of the disease, when it lapses into the acute 
form. It usually comes on at the same changeable seasons that excite 
the acute attacks, but may be present in greater or less conspicuous- 
Bess throughout the year. In this case it is more troublesome during 
the winter months. 

There is a sense of discomfort, perhaps ill defined, but annoying, 
in and about the throat, sometimes extending to the larynx or even to 
the trachea. When these lower air-passages are involved, it is often 
in consequence of cold, damp, chilling winds from the Northwest. 
Pressure over the larynx or the hyoid bone reveals tenderness and 
soreness of the parts, suggestive of perichondritis or periostitis. The 
patient is conscious of an indefinite sensation described as a constric- 
tion or an aching, which is increased by considerable use of the voice. 

The laryngeal mucous membrane is not generally involved to 
the extent of producing hoarseness or presenting positive indications 
of the disease on laryngoscopy. 

Diagnosis. — This disease must be differentiated from the simple 
inflammation of the throat and from tuberculosis, syphilis, and can- 
cer. However, the spasmodic, intermittent, and characteristic history 
of this trouble ought to facilitate the forming of an opinion. The 
physical appearances are generally negative as compared with the 
malignant diseases which are distinguished by visible lesions. In the 
latter diseases we find the cachexia or constitutional condition indi- 
cated by the particular infection in each instance. 

Prognosis. — If the rheumatic or gouty habit has not existed too 
long, or is not of too severe a type, the prospect of relief as the result 
of treatment is good. The disease is not dangerous. 

Treatment. — The internal medication consists of that already 
described for the acute form, with the addition of a prolonged use 
of lithium. This remedy should be taken in appreciable doses rather 
than in the so-called lithia-waters extensively advertised in the news- 
papers. These waters often contain so little lithia according to the 
admittedly correct analyses that one must needs swallow the startling 
draught of six thousand gallons of water to get an ordinary dose of 
lithia. The most convenient preparation is a tablet of effervescent 
citrate of lithia containing 5 grains, kept dry by absorbent cotton. 
Two or three of these are dissolved in a large glass of water — the 
more water, the better — and taken once or twice a day for months 






158 CHROXIC RHEUMATIC SORE THROAT. 

in succession until the rheumatic or gouty habit is overcome. I have 
known of no serious disturbances following the prolonged use of lithia 
in this form, although I have given it over very protracted periods. 
A few persons are susceptible and have symptoms of strangury if too 
much is taken. Others do not use a sufficient quantity of water and 
have a slight gastric disturbance. Alkalithia and the effervescent 
citrate of lithia, soda, and potash are also very effective. 

The sufferers from this disease, like most other people, drink too 
little water to dissolve the waste-elements of the body and eliminate 
them. We flush the sewerage system of a city to increase freedom 
from infection; but how much more important it is to flush the 
sewerage of the body and wash out the waste-products of tissue 
metamorphosis and prevent infection of the system by the results 
of decomposition! The success of the water-cures in these diseases 
lies largely in the amount of. water passed through the body, taking 
up the debris of the tissues and dissolving out the urate of soda from 
the joints, the liver, and the more alkaline tissues, in which it is stored 
only to enter the blood when it becomes sufficiently alkaline in reac- 
tion and then to rack the body with pains. 

The clothing should always be sufficient to keep the person as 
warm as comports with comfort, and wool is preferable to silk, for it 
is a more perfect protective against rapid changes of the temperature. 
Cotton or linen must never be worn next to the skin. The bowels 
must be kept regular. 

If sensitive spots are detected in the throat or larynx, a 10-per- 
cent, solution of carbolic acid in glycerin can be applied to the painful 
area. By the use of this combination the local anaesthetic effect of 
the carbolic acid affords relief without cauterizing the tissues. 






CHAPTER XII. 

DISEASES OF THE PHARYNX (Continued). 
Sore Throat or Measles, Scarlet Fever, axd Small-pox. 

SORE THROAT OF MEASLES. 

The mucous membrane of the throat often participates to a 
large degree in the eruption of measles, and, although it generally 
is not severe enough to require" special treatment, I have seen it so 
intensely involved as to necessitate as persistent efforts as the diph- 
theric throat. In this class of cases the mortality amounts to 80 per 
cent. 

If the throat is examined about the time the fever appears it is 
found to be hypersemic, and this condition increases to a congestion 
by the third or fourth day of the fever when the eruption is noted. 
In the membranous form an exudation occurs that closely resembles 
the false membrane of diphtheria. If this is removed, an uneven, 
raw-looking, ulcerating surface is found beneath. The inflammation 
and exudation cover the soft palate, uvula, tonsils, and posterior 
pharyngeal wall in severe cases. The swelling of these parts is great, 
the velum palati is paretic, swallowing is torturesome, and the tongue 
and general condition are indicative of a grave disease. The ulcer- 
ative process may extend deeply enough into the tissues to terminate 
in abscesses. Instances of Eustachian tubal catarrh and middle-ear 
complications are numerous. 

The larynx is often invaded in measles, but generally only to 
the extent of setting up a catarrhal condition such as commonly af- 
fects the trachea and bronchial tubes; but, if the diphtheric form of 
measles afr ects the larynx, the outlook is a very discouraging one, for 
four out of five of these cases die. 

Treatment. — The simple catarrhal sore throat requires treatment 
principally to prevent middle-ear involvement. The measures rec- 
ommended for acute pharyngitis are sufficient, but the membranous 
form should be treated with as unremitting thoroughness as diph- 
theria, the local treatment for which is indicated here. (See chapters 
on "Diphtheria.") 

(159) 



160 SORE THROAT OF SCARLET FEVER. 

SORE THROAT OF SCARLET FEVER. 

As in measles, so in scarlatina, the pharyngeal mucous membrane 
is generally concerned, but in the simple form of the disease the 
throat involvement is not serious. In the severe form the membrane 
becomes intensely injected and of a dark-red color. Infiltration of 
the tissues produces swelling that is apparent to the eye on inspection, 
and even the neck may present a swollen appearance. The glandular 
bodies with which this region is so richly supplied — the tonsils and the 
parotid, submaxillary, and lateral cervical glands — may all be invaded 
by an intense phlegmonous inflammation with resulting abscesses. 

The throat may be inflamed even when the eruption of scarlet 
fever is absent. As in measles, the swelling and oedema involve the 
soft palate as well as the pharyngeal walls, and suppuration and ab- 
scesses may occur if the necrotic process extend deeply into the sub- 
mucous tissues. Middle-ear diseases more often result from scarlatina 
than from measles, and the results are far more disastrous than from 
measles. Suppuration of the tympanic cavities with resulting granu- 
lations, polypi, extensive caries, and necrosis, as well as a high degree 
of deafness, are frequently attributable to scarlet fever. 

A malignant type of this disease occurs that takes on the form 
of diphtheria. The throat symptoms do not make their appearance 
until a week or longer or until the exanthem and fever have disap- 
peared. Then the throat is attacked, the submaxillary glands swell, 
the throat is covered with a diphtheric membrane, a foul discharge 
takes place, and the breath acquires a fetid odor. The larynx is some- 
times invaded, producing the croupy form of scarlatina. The glands 
at the angle of the jaw may suppurate, and the resulting absces- 
breaking outward, leave scars at this point. 

The diagnosis is aided by the presence of an epidemic, and doubt 
is set at rest by the appearance of the eruption. In the membranous 
form culture-tests for the presence of the Klebs-Lofrler bacilli should 
be made to determine whether or not we have to deal with true 
diphtheria, and in the absence of bacteriological facilities the disease, 
as far as the throat is concerned, at least, is to be treated on the 
theory that it is diphtheria. 

The prognosis in scarlet-fever sore throat, if this is a prominent 
feature of the disease, must be guarded, for the throat affection often 
causes death. In the simple form it is not dangerous; but in the 
severe, or anginose, form about 25 per cent, die, and about 50 per 






FOLLICULAR PHARYNGITIS. 161 

cent, of the diphtheric cases prove fatal without the antitoxin treat- 
ment. 

Treatment. — Aside from general treatment, which is properly 
left to general works on medicine, the throat should receive special 
attention when it gives promise of becoming seriously involved. In 
the first stage of the inflammation cold, in the form of an icebag 
(Fig. 194), may modify the intensity of the inflammation and avert 
or retard the tendency to suppuration. The throat-tablets and other 
remedies recommended in the treatment of acute pharyngitis are 
more effective than gargles. In the pseudomembranous form, which 
may prove to be a diphtheric complication, the treatment for diph- 
theria must be followed. Rufus P. Lincoln recommends the appli- 
cation of pyoktanin. 

SORE THROAT OF SMALL-POX. 

The pustular eruption of small-pox makes its appearance in the 
throat in many cases, and I have seen it extend forward to the buccal 
cavity. The amount of the throat eruption corresponds to the viru- 
lericy of the attack. The swelling and inflammation may become suf- 
ficient to cause pain and difficulty in swallowing. The inflammation 
extends in many instances to the larynx and trachea, and the result- 
ing cedema has caused suffocation and death (Plate VI). 

In mild attacks there is no danger; but invasion of the larynx 
is a grave complication. 

Treatment. — The cleansing and disinfecting sprays followed by 
the protective and emollient and oily preparations given in Chapter 
I are indicated. If the cedema extend to the larynx, scarification must 
be resorted to in order to prevent suffocation, and indeed it may be- 
come necessary to intubate or perform tracheotomy. In the diph- 
theric form resort must be had to the treatment described in the 
chapters on "Diphtheria." 

Follicular Pharyngitis. 

Synonyms. — Folliculous, or granular, pharyngitis; clergyman's 
sore throat. 

Pathology. — There are two forms of follicular pharyngitis, — the 
hypertrophic and the exudative. In the first form the follicles are 
enlarged and stand out prominently upon the membrane, while in 
the second, or exudative, form there is a secretion of a light color, 

11 



162 FOLLICULAR PHARYNGITIS. 

which may become dried and cheesy in consistence and appearance. 
In the hypertrophic condition the morbid changes are epithelial 
rather than follicular, but in the exudative form the follicular tubules 
are distended and their walls thickened, and chalky deposits are some- 
times found within the follicles. 

In the case of public speakers the severe tests to which the vocal 
organs are put increase the demands on the glandular elements to 
furnish an extra amount of the lubricating secretions. This pro- 
tracted exercise results in increased blood-supply and deposit of nutri- 
ment, or an excess of growth of the glandular tissues, and this, 
together with occlusion of the apertures of the follicles, accounts for 
their hypertrophic condition. Irritating discharges from the naso- 
pharynx serve to excite inflammation in the orifices of the follicles, 
resulting in their constriction or obliteration. 

Etiology. — It is not a simple matter to account for this disease, 
for it exists in young children who are not exposed to the irritants to 
which the disease is usually attributed: excessive use of the voice, the 
inhalation of dust, gases, smoke, etc. There seems to be an inherent 
tendency to a proliferation of cells in the mucosa. It is especially 
prevalent in those having the strumous diathesis. Old age seems 
quite exempt from this form of throat trouble, but presents the 
atrophic stage of pharyngitis. 

Symptomatology. — In the early stage of this disease the patient 
complains of dryness of the throat or a tickling sensation that occa- 
sions frequent efforts to relieve, and a slight hacking cough. The 
voice assumes a husky quality and tires after speaking or singing a 
short time, and while using the voice transitory lancinating or shoot- 
ing pains occur. 

The dry stage is followed by a mucous secretion which is often 
stained with pns or blood. The discharge is usually thick and tensile, 
and clings to the posterior pharyngeal wall or sticks to the posterior 
surface of the velum. If it is not too abundant it dries into scales or 
crusts. The membrane covering the back wall of the pharynx is 
studded with several spongy, red masses, or is sometimes quite cov- 
ered with them. They are in some instances punctated, appearing 
like little nipples; in others they have broad bases, are flat, and lie- 
come coalesced in patches. Behind and external to the posterior 
faucial pillars their union forms a ridge extending upward and out- 
ward toward the Eustachian orifices. The blood-vessels are engorged 
and the veins are abnormally prominent. 



FOLLICULAR PHARYNGITIS. 163 

The tonsils are enlarged in a considerable proportion of these 
cases and the uvula is relaxed and tickles the tongue (Plate III). 
The membrane intervening between the follicles may be atrophied 
and of a grayish-white color that will convey an impression, at first 
sight, of pus. 

Diagnosis. — Cohen mentions the presence of ulcerated patches 
in this affection, which "would render one liable to mistake this for a 
syphilitic throat, but I do not remember to have encountered this 
condition. Eliminating the question of ulcers, which must be very 
rare, there is little likelihood of this being mistaken for syphilis or 
tuberculosis. 

Prognosis. — If let alone follicular pharyngitis may be expected 
to invade the larynx and seriously affect the voice for speaking and 
ruin it for singing, or it extends to the Eustachian tubes and through 
them to the middle ears, resulting in hypertrophic or sclerotic catarrh 
of these important organs. At last the history of this disease brings 
us to the fourth stage of throat catarrh, or atrophic inflammation, 
resembling atrophic rhinitis. 

Treatment. — The physician does not often enjoy the opportunity 
of treating this disease in its early stages, for the symptoms are not 
urgent enough to suggest the need of medical services. As in the 
other inflammatory processes, cleanliness is the first prerequisite. The 
alkaline and antiseptic washes and the oleaginous sprays discussed 
in the chapter on those subjects are useful here. After perfectly 
cleansing the nose and throat, for this is the first step in the treat- 
ment, the follicles, two or three at a sitting, should be reduced by 
the application of chromic acid, London paste, or — better still — the 
galvanocautery. If the acid or paste is used, great caution is neces- 
sary not to let it drop into the larynx or oesophagus or spread it upon 
the surrounding membrane. The chromic acid is applied in the form 
of a bead of the crystals fused upon the platinum wire-loop applicator 
(Fig. 182). The London paste is applied in small particles so that 
they will adhere like minute spots of plaster on the surface of the 
follicles. 

The galvanocautery (Fig. 31) is the most satisfactory means of 
eradicating the tumefied follicles. The long electrode is chosen ac- 
cording to its fitness for the particular condition present and applied 
to the apex or centre of the follicle before the current is turned on. 
Then the circuit is closed for an instant until the tumefaction is 
burned so as to destroy it to a point a little below the surface of the 



164 MEMBRANOUS SORE THROAT, NON-DIPHTHERIC. 

adjacent membrane. On the following day the hypertrophied tissue 
is seen to have given place to a gray surface that will be cast off 
as a slough in about a week. By repeating this process a number of 
times all the enlarged follicles can be dispersed. In the meantime 
cleansing, soothing, and protective remedies should be applied in the 
form of sprays, such as a 3-per-cent. solution of camphor-menthol, 
benzoinated lavolin, and a 4-per-cent. solution of eucalyptol in lavolin. 
These should be used once or twice a day, preferably at bedtime and 
on rising in the morning. 

General treatment is demanded by a uric-acid diathesis to pre- 
vent rheumatic or gouty attacks in the throat, and if the digestion is 
faulty or the eliminative functions are impaired, remedies must be 
addressed to these conditions. The local treatment is often aided by 
tonics and alteratives. 

Membranous Sore Throat, Non-diphtheric. 

Synonyms. — Simple membranous sore throat; herpetic pharyn- 
gitis. 

Pathology. — There occurs occasionally a form of sore throat 
characterized by an exudate that covers the pharynx and fauces, and 
extends upward and forward toward the hard palate on its inferior 
surface, resembling the diphtheric membrane. This is the result of 
an herpetic eruption in the throat, the blisters of which rupture and 
cover the mucous membrane with their contents. 

Etiology. — The cause of this affection is not known, but it is 
more prevalent during epidemics of diphtheria than at any other time. 

Symptomatology. — The initiatory symptoms are very much like 
those of diphtheria, except that they are of diminished intensity. 
There are chills; fever of 101° or 103° F.; rapid pulse; dim. 
indented tongue; dry throat, with burning pain; and difficulty of 
swallowing. Blisters are often found coincidently on the lips. 

In the beginning of the attack the membrane of the throat is 
of a deep-red color and is dotted with follicles that are inflamed or 
pustular in character. As these pustules rupture and their contents 
escape over the surrounding surface the appearance of a false mem- 
brane is given to such patches. The seat of each ruptured pustule 
may become an ulcer, and these grouped together present irregular 
areas of ulceration. 

Diagnosis. — Simple membranous sore throat may be confounded 
with diphtheria, but it is not so grave a disease. Although it may 



MEMBRANOUS SORE THROAT, NON-DIPHTHERIC. 165 

be ushered in by symptoms simulating diphtheria and with a high 
fever, generally all the symptoms are of a milder grade. The simple 
membrane is much thinner, — indeed, one can almost discern the mu- 
cous membrane beyond, — while in diphtheria the false membrane is 
three or four millimetres thick and closely adherent to the surface 
beneath. In the simple disease the membrane is easily detached by 
means of cotton on a carrier, leaving a smooth surface, while detach- 
ment of diphtheric membrane, reveals raw, uneven, ulcerating tissues 
exposed to view. Bacteriological examination in diphtheria shows 
the presence of the Klebs-Loffler bacillus, which is the germ of that 
disease, while the tests of the simple form are negative. The sputa 
and sections of the membrane should be submitted to the culture- 
tests in this or any other disease in which diphtheria is suspected. It 
has become an easy matter in large cities like Chicago, where there 
are laboratories for such purposes and the health department of the 
city government conducts such experiments. 

Prognosis. — This disease in itself is not dangerous, but it should 
not be forgotten that true diphtheria sometimes is ingrafted upon it, 
especially during epidemics. 

Treatment. — During the first stage, when the fever is high, 
guaiacol diluted one-half with glycerin and applied with cotton on 
a holder mitigates the symptoms, and is indicated on account of its 
effect in reducing the temperature. It is best not to use it in full 
strength, for it has sometimes appeared to have a destructive effect 
on the mucous membrane, and we have found on the day following its 
application an ulcerated surface corresponding to the area touched 
with the pure guaiacol. Hydrozone should be sprayed into the throat 
every few hours, the intervals depending on the rapidity with which 
the false membrane is formed. But it is not necessary to use it fre- 
quently if it cause much smarting and burning, for the gravity of the 
disease does not warrant it. If considerable pain is produced by the 
H 2 2 , it probably contains too large a proportion of acid and requires 
dilution. In gals prefers the following pigment: Morphise sulphatis, 
gr. iv; acidi carbolici, gr. xxx; glycerini, fgj; to which he adds 30 
grains of tannin when an astringent is required. John Xorth has 
stated to me that potassium permanganate will dissolve the false 
membrane. He uses 30 grains to the ounce of water. 

Inhalations and sprays are more easily applied and cause less dis- 
comfort than swabs and probangs. I have seen much relief afforded 
by adding 10 drops of pure camphor-menthol to a pint of hot water 



166 MEMBRANOUS SORE THROAT, NON-DIPHTHERIC. 

for the patient to inhale through the mouth. A benzoinol inhaler 
(Fig. 22), an ordinary tea-kettle, small tea-pot, or coffee-pot can be 
pressed into service for this purpose. The nozzle is wrapped with sev- 
eral thicknesses of cloth, not occluding the opening itself, so as to 
prevent burning the lips, and the end of the nozzle is taken between 
the lips while the steam impregnated with the fumes of the medicine 
is drawn gently into the throat. This has given good results in other 
forms of sore throat. Carbolic acid in glycerin, of 5- or 10-per-cent. 
strength, will deplete the blood-vessels and anaesthetize the mucous 
membrane sufficiently to relieve pain. Sprays of eucalyptol, camphor- 
menthol, or salol in 3-per-cent. solutions — after the alkaline antiseptic 
sprays already given in Chapter I — have a refreshing effect. 

The general treatment, diet, and hygienic and prophylactic meas- 
ures appropriate to this disease are the same as those recommended 
in the treatment of coryza and acute pharyngitis. 



CHAPTEE XIII. 

DISEASES OF THE PHARYNX (Continued). 
Diphtheria. 

Unlike the sore throats of scarlatina, measles, and small-pox, 
in which a pharyngeal manifestation is not a necessary element of 
the disease, or in which, if it exist, it is merely incidental to a con- 
stitutional malady, in diphtheria we recognize a veritable throat 
affection with systemic infection. The importance of the disease and 
the advancements recently made in its pathology and treatment war- 
rant an extended presentation of the subject. 

Since the discovery of the microbe which causes diphtheria by 
Klebs, in 1883, the method and nature of the disease have been 
illuminated by the researches of Loffler, Eoux, Welch, Prudden, and 
others. 

Pathology. — In true diphtheria there is always present in the 
membranous deposits in the throat a micro-organism that is not found 
in like exudates of other diseases. This microbe is easily differenti- 
ated from others and can be isolated and propagated in culture-tubes. 
When animals like guinea-pigs and rabbits are inoculated with this 
organism the disease which produced the microbe is reproduced in 
the susceptible animals. Extensive experiments and studies by sci- 
entific observers have conclusively demonstrated that this disease is 
one of local origin, with constitutional phenomena, depending upon 
the absorption of a poison generated by the specific micro-organism. 
The false membrane of diphtheria abounds in these microbes in its 
superficial layers, but they are not found in the stratum next to the 
mucous surface, and generally not in the mucous membrane itself. 
The poisonous principle evolved by this microbe is comparable to the 
venom of serpents, and in this connection it is instructive to observe 
that in contrast to this deadly microbe another is found identical with 
it in biological and morphological characteristics, but lacking in the 
power to destroy the lives of susceptible animals. This has been 
termed the false, or pseudodiphtheric, bacillus. Concerning the vari- 
ations in the pathogenic properties and powers of these bacilli, 

(167) 



168 DIPHTHERIA. 

Abbott says, in the Medical News for November 17, 1894: "It was 
observed that the genuine, virulent diphtheria bacillus was liable to 
fluctuate in the degree of its pathogenic properties, at times possess- 
ing these to such an extent that, when inoculated into guinea-pigs., 
death resulted in from thirty-six to forty-eight hours, while again the 
period of inoculation was much longer, often reaching five or six 
days, and in not a few cases organisms were obtained from undoubted 
cases of diphtheria that failed to give more than a temporary local 
reaction when inoculated into these animals." 

The micro-organism of diphtheria is named the Klebs-Lofner 




Fig. 75.— Diphtheria Bacilli. (After Krieger.) Culture on agar-agar, 

twenty-four hours old; stained in alkaline methylene- 

blue; magnified 1000 times. 

bacillus (Figs. 75 and 76), after the scientists who have brought to 
light the germ that causes untold suffering and a vast waste of human 
life. When this bacillus comes in contact with a mucous membrane 
or with abraded skin an inflammation is excited. The conditions 
then are favorable for the development and propagation of bacilli, — 
warmth and moisture, — and, while the microbes themselves do not 
enter into the lymph or blood circulation, their poisonous product 
does. In this manner an infection of the whole system takes place. — 
a toxaemia of specific type. This poison introduced into the blood 
of guinea-pigs and rabbits in minute quantities produces death, and 
its potency is retained for long intervals in a vacuum. According to 



DIPHTHERIA. 



169 



Yersin and others, the bacillus itself is not virulent, but the poisonous 
product of the microbe is the material that causes paralysis in sheep 
and dogs, and death in rabbits. A similar bacillus is also found in 
the mouths of individuals who have never had diphtheria and who 
have not been exposed to it. To all appearances this is the true 
Klebs-Lofner bacillus deprived in some way of its virulency. It may 
have become modified or attenuated, but whether its poison-producing 
powers can become revivified is not known. These facts demonstrate 
that practically two diseases have formerly passed under the name of 




Fig. 76. — Diphtheria Bacilli. (After Krieger.) Culture on blood- 
serum, prepared as Fig. 75; magnified 1000 times. The short form pre- 
sented in this specimen is due to their rapid multiplication. Some of the 
germs are distinguished by a club shape, which is considered characteristic 
of this species. 



diphtheria, just as previously to the present century scarlatina and 
measles were supposed to be identical. 

In true diphtheria the infection and toxgemic condition are pro- 
duced by the Klebs-Lofner bacillus, but in false diphtheria this ba- 
cillus is absent or is changed in character, and in its place are found 
the streptococcus longus, the streptococcus pyogenes (Fig. 77), and 
the staphylococcus. 

False diphtheria is a much milder disease than the true form and 
is far less frequently productive of paralysis. Although these two 
forms of the disease cannot be differentiated except by bacteriological 



170 



DIPHTHERIA. 



methods, Baginsky, Virchow, Henoch, Smith, and others recognize 
the dual character of the disease. In the true form the streptococcus 
and staphylococcus are often found associated with the Klebs-Loffler 
bacillus, and even the internal organs are invaded by the cocci, where 
the bacilli of true diphtheria do not penetrate. The cocci have been 
found in the lungs and kidneys as well as in abscesses of the neck. 

The bacillus of true diphtheria is possessed of remarkable vitality 
and may convey the disease after months and even years of latency. 
D'Espine and others found their potency unimpaired in cultures of 
sixteen months. Cases are on record in which infection occurred 





n%* -iSiPi^ 




Fig. 77. — Streptococcus Pyogenes. (After Krieger.) Streptococci and 
leucocytes of human pus; stained in gentian-violet; mag- 
nified 1000 times (Pfeiffer and C. Fraenkel). 

from clothing and other articles after as many as twenty years, and 
these are authenticated by observers of undoubted competency and 
credulity. 

Diphtheria usually attacks persons under the age of 30 years, but 
may occur at any period of life. Its relative frequency in the very 
early years would almost justify the designation of a disease of child- 
hood. Out of 151.2 cases in one statistical table I find that 1309 oc- 
curred in children under 6 years and only 203 from 6 to 17 years. In 
another table including adults 70 per cent, of the cases were under 
18 years, 20 per cent, were between 18 and 30 years, and only 10 per 
cent, were above 30 years. It has been observed very infrequently 



DIPHTHERIA. 171 

in infants less than 6 months old; but at this age the organism 
appears to be nearly immune against this disease. 

The period of incubation varies greatly, there being as wide a 
margin as from one to twenty days. In animals directly inoculated 
the variation is only from half a day to three days. The sooner the 
disease makes its presence known, the more virulent is the type of 
attack. When the onset is slow and sluggish it seems to indicate 
either the modification or attenuation of the infecting germ or the 
strong power of resistance of the system. 

Etiology.— Diphtheria is not a sporadic disease, since it cannot 
arise in a body independently of any extraneous cause. It can re- 
produce, but cannot produce, itself. The disease originates in any 
individual in the following manner: The specific micro-organism 
known as the Klebs-Loffler bacillus gains lodgment upon the mucous 
membrane or denuded skin. There it grows and multiplies, and dur- 
ing this development of cultures of the germ a poison is produced 
that is chemically analogous to the venom of serpents, and the analogy 
may be extended to include its virulency. The resulting pathological 
manifestation is a reproduction of the disease whence the infecting 
germ was derived. An exposure of a- susceptible person to the specific 
microbe for only an instant may be sufficient to insure its reception 
upon a favorable soil; and so rapid is the process of propagation and 
toxaemia that a few hours — or days, at most — witness the develop- 
ment of this plague of nations. 

Abbott, in the Medical News for November 17, 1894, speaking 
of the Klebs-Loffler bacillus, pithily puts his views in these words: 
"If this agent is present, diphtheria exists; if it is absent, then the 
local conditions and constitutional manifestations must be attributed 
to some other cause, and the disease is not diphtheria." The vitality 
of the bacillus, extending over many months or years, seems to insure 
the enduring nature of this decimator of communities. This is not 
an exaggerated characterization, for I have been in an epidemic that 
has literally annihilated family after family of children Until the 
population was dazed by the devastation. 

Contact of persons with those who are,. or have been, suffering 
with diphtheria is not necessary to constitute exposure. Merely the 
inhalation of a patient's breath, or being in the same room, or being 
in the presence of one who has been in such a situation and who may 
carry the infection in his clothing, or handling a book between the 
leaves of which the germs may have found their way, may result in 



172 DIPHTHERIA. 

communicating the disease. The bearing these facts have on the use 
of library books and the antiquated form of kissing the Bible in courts 
and societies is too apparent to need expatiation. 

These germs naturally harbor where millers, moths, and molds 
thrive most. Dark, damp, badly ventilated, and filthy places seem 
to be their appropriate habitat. It is commonly believed that the 
sewers of a city are the conveyers and distributers of this poison. 
Unless the sewer-traps are perfect and the sewers abundantly flushed, 
it is evident how the houses along the line of a sewer-system may be- 
come, one after another, the recipients of a poison entering farther 
up the stream. These microscopical germs are disseminated by vapors 
and winds and they penetrate our homes with escaping sewer-gas. 
This view is substantiated by the fact that the death-rate from diph- 
theria is twice as great in cities as in rural districts, according to our 
vital statistics. • 

The subtle nature of this microbe and its fondness for its vic- 
tims and its vitality and power of propagation are suggestive of the 
multitudinous ways of infection and of the necessity of unceasing 
vigilance to escape it. One never knows when a child in school or in 
a public conveyance may be sitting beside a diphtheric individual, and 
it seems as though no argument were needed to show the absolutely 
dangerous character of the universal habit of kissing children, who, 
in fact, are much more susceptible to this deadly disease than the 
adults who wantonly expose them. 

Surgeons have contracted diphtheria and many have lost their 
lives by means of a particle of the membrane or discharges from a 
patient's throat coughed into their eyes or upon their lips or by re- 
ceiving it upon an abraded surface of the skin. When making ex- 
aminations of the throat they have forgotten either to wear protecting 
glasses over their eyes or to keep at one side of the line of the column 
of air expelled by coughing. 

The lower animals are subject to attacks of diphtheria. Pigeons, 
turkeys, and cats have communicated it to the human family in vari- 
ous authenticated instances. Hence the unappreciated danger of 
allowing children to pet and caress sick cats is apparent. Eabbits 
and guinea-pigs are susceptible to the diphtheric virus, and cows' 
milk has been known to convey this disease, as it does scarlatina. 

Symptomatology. — There is a very wide margin of varieties in 
both the local and systemic manifestations of diphtheria. The disease 
may appear in a very mild form, or there may be a severe throat 



DIPHTHERIA. 173 

inflammation with distressing local symptoms and alarming and fatal 
constitutional disturbances. The period of incubation is generally 
from two days to a week, and is characterized by sensations of chilli- 
ness, waves of heat, headache, weariness or sleepiness, and depression 
of spirits. Following these premonitory symptoms are more pro- 
nounced ones announcing a serious involvement of the digestive and 
circulatory systems. Loss of appetite, nausea, vomiting, and diar- 
rhoea occur, and are accompanied by thirst and increase in the force 
and frequency of the heart's action. Heat and dryness of the throat; 
stiffness or soreness in the muscles concerned in the act of swallowing, 
which is a painful procedure; and tenderness on pressure under the 
angle of the jaw indicate the localization of the pathological process in 
the throat. 

The temperature rises to 101° F. in the first stage and sometimes 
as high as 104° F. Adults are more likely to complain of headache 
and backache than children. An erythematous eruption occasionally 
appears during the first stage. Inspection of the throat within the 
first few hours of the seizure reveals a reddened, swollen condition of 
the mucous membrane of the soft palate and tonsils. All the symp- 
toms are not present in every case. One must expect to find some of 
these lacking, and a description that will accurately fit one case may 
vary widely of the mark if applied to the next. But we would best 
consider typical cases. 

The second stage is that in which the false membrane is formed 
and the presence and proliferating powers of the diphtheria bacillus 
are demonstrated. The first appearance of this disease-label — which 
is usually within the first day or two of the onset — is a thick, yellow 
secretion, which can be seen covering the tonsils. A little later a 
yellowish-gray or a dirty, grayish-white, false membrane is seen to 
have made its appearance in the fauces and pharynx, increasing in 
thickness and extent until little can be seen but this reeking back- 
ground to a painful picture. If pieces of this adventitious tissue are 
detached from the mucous membrane, to which it is closely adherent, 
the latter is seen to appear rough, raw, granular, and bleeding. All 
the groups of glands in the vicinity of the throat become indurated 
and sensitive. 

The high temperature usually falls after the full development 
of the exudate in the pharynx, and may reach the normal on the 
fourth or fifth day. Decomposition of the secretions of the throat 
causes an offensive breath, which may often be observed the instant 



174 DIPHTHERIA. 

one enters the patient's room. The profound impression of the diph- 
theric virus on the circulatory system is evident from the feebleness 
of the pulse, which is compressible and abnormally rapid or slow. 
The kidneys participate in the general systemic disturbance, although 
the diphtheria bacillus itself does not penetrate to them; and the 
urine is decreased, high-colored, and rich in urea, and often in al- 
bumin also. 

About the third or fourth day there may occur an extension 
downward of the disease into the larynx with unmistakable signs of a 
serious complication. The respiration is harsh and embarrassed and 
a dry cough reveals the hoarseness of the voice. Increasing con- 
striction of the laryngeal cavity is evidenced by distressing dyspnoea, 
blueness of the lips and finger-nails, pufnness of the face, and in- 
creasing dullness of the intellect until unconsciousness and fatal coma 
come to the sufferer's final relief. 

Other complications result from an extension of the disease to 
the nasal cavities, followed by a thin, yellow or dark, foul discharge 
from the nose, excoriating the skin about the nostrils and on the 
upper lip. Invasion of the nasal ducts may lead to involvement of the 
eyes; or extension to the Eustachian tubes may presage invasion of 
the middle ears with the train of consequences following in the wake 
of a suppurative middle-ear inflammation of a diphtheroid type. 

The third stage results in resolution or death. This period of 
the disease begins at about the end of a week, when all the racking 
symptoms may gradually melt away with the loosening and exfolia- 
tion of the false membrane. The general condition shows a refresh- 
ing improvement, — a sunshine of calm succeeding a physical storm. 
The fever is gone, the pulse drops to the normal rate, painful swallow- 
ing disappears, desire for food returns, the kidneys and skin perform 
their functions naturally, and all but the strength may now return 
to par. 

Unless a relapse occurs, or the heart has been too profoundly 
implicated so as to incur the liability of syncope, or diphtheric paraly- 
sis follows the attack, the patient pursues a normal course to complete 
recovery. 

In case the infection is of an intensely virulent type and finds 
the powers of resistance weakened, the system yields to the irresistible 
invasion of the virus and succumbs to coma and death. 

This is the natural history of a typical attack of diphtheria unin- 
fluenced by the efforts of man to avert or modify its progress. Be- 



DIPHTHERIA. 175 

tween this type and simple membranous sore throat there are great 
variations in the virulency of the infection and its manifestations. 

Diagnosis. — Simple membranous sore throat and ulcerative ton- 
sillitis are the most likely to confuse the practitioner in differentiat- 
ing between diphtheria and other pharyngeal affections; but the 
exudative form of sore throat in measles and scarlet fever also closely 
resembles true diphtheria. The presence of a diphtheric epidemic, 
the rapid development of the symptoms, and the closely adherent, 
leathery membrane are definite diagnostic features. The membrane 
of the other diseases is thin* and easily wiped off with cotton, leaving 
generally a smooth membrane beneath, instead of a rough, ulcerating, 
or bleeding surface. The absence of the skin-signs of measles, scar- 
latina, and erysipelas aid in excluding those diseases, although very 
exceptionally an erythematous rash occurs in the first hours of diph- 
theria. 

From throat inspection alone it is impossible to distinguish be- 
tween diphtheria and other forms of pharyngitis before either a false 
membrane forms or an eruption appears, so that it is then necessary 
to be conservative in expressing an opinion, and to treat the case as 
though it were expected to terminate in diphtheria. 

A positive diagnosis is possible if a bacteriological examination 
prove the presence of the Klebs-Lofner bacillus. Other microbes may 
be present and embarrass the results of treatment, but the nature of 
the infection is established. It must not be forgotten, however, that 
another micro-organism identical with the Klebs-Lofner bacillus, to 
all appearances, is sometimes found, but differing from it in that it 
produces a milder affection. The disease characterized by this mi- 
crobe should be termed "diphtheroid," analogously to the formation 
of the term "typhoid 7 " from typhus. As soon as any symptoms exist 
to excite a reasonable doubt as to the possibility of the disease being 
diphtheria, the secretions, and especially any available false membrane 
from the throat, should be secured in a perfectly clean, sterilized test- 
tube and submitted to the microscope and culture-test by a competent 
bacteriologist whenever it is possible to do so. Where it is not prac- 
ticable, the treatment should be conducted on antidiphtheric princi- 
ples until a positive diagnosis can be rendered. 

Prognosis. — This is one of the most fatal of the diseases that 
afflict humanity; but, in view of all the evidence adduced, it is cer- 
tain that the death-rate has been reduced since the introduction of 
serum-therapy. Notwithstanding this, the physician should always 



176 DIPHTHERIA. 

recognize the possibility of a fatal termination even nnder the most 
favorable circumstances for treatment. If the infection is of a mild 
type and the resisting-powers of the patient are strong, the chances 
of recovery are good. The majority of such cases get well; but one 
cannot tell when such a case may take on a virulent form of the dis- 
ease that rapidly leads to collapse. 

Patients often succumb in a day or two after the seizure, and 
the majority of fatal cases die by the fifth day. In very young chil- 
dren, at the age when tenacity upon life is feeble, this disease rages 
with a fearful mortality. Signs of the gravity of an attack are in- 
vasions of the nose, ears, larynx, and trachea; haemorrhages; purpuric 
eruption; suppression of the urine; vomiting, and diarrhoea. In 
laryngeal stenosis without intubation or tracheotomy the death-rate 
reaches the appalling figure of 95 per cent. A large number of sud- 
den deaths are attributed to heart-failure. 



CHAPTEE XIV. 
DISEASES OF THE PHARYNX (Continued). 

Diphthekia (Continued). 

Treatment. — Since diphtheria is primarily a local disease with 
secondary constitutional infection, in this respect comparable to syph- 
ilis, we will take np the consideration of medicinal treatment in the 
logical order suggested by the sequence of the phenomena that con- 
stitute its history: (1) local and (2) constitutional treatment, — both, 
the classic method and the modern serum-therapy. But coincidently 
with the beginning of treatment certain preliminary precautions must 
be observed for the conduct of any given case to a successful issue, 
and also for the protection of other members of the family and the 
community. 

In addition to observing the patient's pulse, temperature, and 
respiration, and other physical signs and symptoms, the throat and 
nose should be examined in such a way as to avoid the possibility 
of the physician himself becoming infected. Instead of occupying a 
position immediately in front of the patient while inspecting the 
throat he should be at one side and on the alert to dodge any of the 
discharges from the throat that may be expelled by a sudden, ex- 
plosive cough. Otherwise a lodgment of the venomous secretion or a 
particle of false membrane in the doctor's eye or on his lips may cost 
him his life. Moreover, cases have occurred in which the expulsion 
of the virus has resulted in its landing in the examiner's beard or on 
his clothing, and the communication of the disease with deadly effect 
to members of his own family or to other patients. The practice of 
holding a small pane of window-glass between the patient's mouth and 
the physician's face is an excellent one. 

The medical attendant of a diphtheric case would best remove 
his coat and vest and wear an operating-gown reaching from his neck 
to his feet, or, in lieu of this, a sheet pinned about his neck and en- 
veloping his person to the feet. After the examination, his hands, 
face, and beard should be washed with a solution of bichloride of mer- 
cury, 1 to 10,000. The instruments used should be boiled over a very 

12 ( 177 ) 



178 TREATMENT OF DIPHTHERIA. 

hot fire in a solution of carbonate of sodium — an ounce to the pint . 
of water — to disinfect them. All utensils, handkerchiefs, napkins, 
etc., used by the patient must be treated in the same manner. 

Assuming that the examination reveals the presence of diph- 
theria, or even a condition that excites a suspicion of that disease, the* 
patient must at once be isolated from all except the medical attendant 
and the nurse. If possible, one or two rooms should be selected away 
from any cellar or basement, above the ground-floor and so situated 
as to admit the sunlight and an abundance of fresh air. All carpets, 
rugs, window-curtains, pictures, draperies, upholstered furniture, and 
unnecessar}^ articles must be removed before the patient is admitted 
into this room. Without exposing the sick one to draughts of air, 
free ventilation should be effected from the tops, not the lower parts, 
of windows. The temperature should be kept uniformly at from 70° 
to 71° F. The body-clothing must be such that children cannot ex- 
pose themselves to cold at night, and this rule should be observed also 
at all times, with children especially, who ought to wear union-suits 
by day and night-drawers at night. These consist (the first) of 
woolen shirt and drawers in one piece and (the second) of cotton- 
flannel or cotton suits made in the same way. The woolen suits are 
to be used in winter and the cotton-flannel for cool, and the cotton 
for hot, weather. The drinking-water must be pure. If there is rea- 
son for the slightest suspicion of the purity of the water it should be 
boiled for fifteen minutes and then chilled, not by placing possibly 
infected ice in it, but by setting it covered in a cold, pure atmos- 
phere in winter or surrounding it with ice in hot weather. Pure 
water made cold by this means is safer than the ice sucked, as recom- 
mended by many writers, since freezing does not destroy disease 
germs. 

The drainage of the house should be inspected to ascertain if 
cess-pools, stagnation, or faulty sewer connections are responsible for 
the sickness. All communication between the outside world and the 
patient must be forbidden, except through the physician and the 
nurse. In order that the contaminated air'of the sick-room may not 
infeci the adjoining apartments, a sheet should be saturated with a 
5-per-cent. solution of carbolic acid and hung over the doorway of 
the chamber. A valuable antiseptic procedure is to have the bedstead, 
floor, and walls washed daily with a solution of mercuric bichloride, 
1 to 10,000. One to 20,000 parts of water will destroy bacteria in 
ten minutes 



TREATMENT OF DIPHTHERIA. 179 

The physician's duties do not end with giving instructions. He, 
himself, must often insist on their observance and personally super- 
intend or execute his own orders if he would save his patient's life. 
As an illustration of the indifference of the average family to the 
commonest sanitary regulations I will adduce a single instance: Upon 
being called to see a girl of 17 years, I found sufficient clinical evi- 
dence to warrant pronouncing her ailment diphtheria. She was lying 
in a bed in a large, but dark, damp, and musty room. On inquiry it 
developed that her brother and father had died of the disease in the 
same room and in the identical bed. I immediately asked to be shown 
the rooms on the floor above, and selected two adjoining apartments 
extending the width of the house, so that windows admitted sunlight 
and air on opposite sides. I directed all the contents of these rooms 
to be removed, excepting nothing but a bed, a table without a spread, 
and a chair without upholstering. Promise was exacted that the pa- 
tient would be removed to these chambers without delay. On the fol- 
lowing day I found the patient where I had left her, and worse. No 
time was lost in informing the family that I would at once withdraw 
from the case, and that I would not make another visit or prescribe 
for the patient at the present time unless they immediately removed 
her to the selected apartments. They had decided that it would in- 
convenience them to do so, but they hastened to comply with my 
demands. Thorough antiseptic measures were adopted, such as had 
not been employed in the cases of the brother and father. Another 
younger child, a sister of the patient, soon was suffering from the 
same disease. She was subjected to the same rigid hygienic measures. 
Both children recovered. One had abscesses in the neck, but no per- 
manent bad results further than scars indicating the points of in- 
cision. Father and son died in the same room, in the same bed, with 
the surrounding conditions described. The two sisters recovered un- 
der conditions made as favorable as possible. Had they been kept 
in the dark, damp, musty, infected atmosphere of the double-death 
chamber, I predicted that the undertaker would soon follow my foot- 
steps. Measures that seem imperative and even harsh may sometimes 
be absolutely necessary to the patient's welfare and the doctor's con- 
science and reputation. 

It is a great advantage to have a skilled nurse to faithfully and 
intelligently execute the physician's directions. She will best carry 
out all the modern methods of care of the sick as perfected in our 
great hospitals. She will be prepared — as no untaught person can 



180 TREATMENT OF DIPHTHERIA. 

be — to observe the aseptic and antiseptic teachings of advanced med- 
icine. Nothing that leaves the diphtheric patient, and that is capable 
of bearing infectious material, should escape a most thorough system 
of sterilization. Instead of napkins or handkerchiefs, cloths should 
be used to receive the matters expectorated, or discharges from the 
nose, etc., and these should be burned with the most scrupulous care 
that not a rag is left. The importance of this and the disinfection 
of sputa is plain enough when we reflect that flies are attracted to 
such refuse, after visiting which they cultivate the acquaintance 
of your susceptible nose, lips, and eyes, or any point of skin denuded 
of its epidermis, and there inoculate your infectious point. Cats 
prowl around the backyard, into which cloths soiled by the diph- 
theric discharges are thrown. These cats contract the disease and 
distribute it throughout the neighborhood. Dame Nature, in an an- 
gry mood, seems to have exercised all her cunning and ingenuity to 
devise unsuspected ways and intricate and invisible means for the 
prolific production and wide dissemination of the germs of this fatal 
plague of the throat. Such considerations led J. Lewis Smith to say: 
"The day will probably never come when we can say of diphtheria, as 
we can of small-pox, that it is virtually suppressed.' - ' 

The sputa should be disinfected, before removal from the pa- 
tient's chamber, by pouring over it enough of a solution of bichlo- 
ride of mercury — 1 to 1000 — to entirely cover the discharges. This 
should remain in the receptacle at least a half-hour and be agitated 
several times to bring all portions of the ejecta into contact with the 
disinfectant. Deodorizing and disinfecting medicaments are vola- 
tilized in the room, much to the patient's comfort. I have observed 
excellent effects from melting menthol crystals in a teaspoon over a 
flame until the air was comfortably impregnated with the fumes. 
When the nose was involved I have taken the hot steaming liquid to 
the bedside and held it where I could blow the fumes over the bed 
toward the patient's face so that he would inhale a considerable 
quantity of them through both the nose and mouth. His eves are 
kept closed, and if not too great heat is used so as to make the fumes 
too dense, without any irritating effects, his nose and throat are 
benefited. If the throat is entirely covered by a thick membrane, of 
course no fumes reach the mucous coat beneath. J. Lewis Smith pre- 
scribed as a prophylactic the fumes of the following prescription: 
I> Olei eucalypti, acidi carbolici, of each, gj; terebinthinae, gviij. 
"Add 2 tablespoonfuls of this mixture to 1 quart of water ami allow it 



TREATMENT OF DIPHTHERIA. 181 

to simmer constantly, near the patient, in a vessel with a broad sur- 
face, as a tin or zinc wash-basin, a vessel with a broad surface being 
needed so that it will not take fire. The vapor produced is strong and 
penetrating, but not unpleasant." 

Local Treatment. — There are remedies that exert a solvent action 
on the false membrane when the latter is macerated in them for a 
considerable time, and this fact has led to their use as gargles and 
local applications hj means of swabs and sprays. Some of these reme- 
dies have too slow and feeble an effect to be of efficient use in the 
throat. Others exert a decided and perceptible influence in dissolv- 
ing the exudate both without and within the body. Such, for ex- 
ample, is sulphocalcin, to which my attention was first attracted by 
William C. Wile several years ago, at a meeting of the Mississippi 
Valley Medical Association, to which he reported a large series of 
diphtheric cases in which unusual success had attended the topical 
application of this remedy. I then introduced it into my practice, 
and am able to confirm Wile's statement of the solvent properties of 
this preparation. In a letter recently received from the doctor he 
reaffirms his previous statements, and says his experience during the 
intervening years has been as satisfactory in the use of the drug as 
his first reports indicated. 

My method of employing the liquid is as follows: Absorbent 
cotton is twisted firmly on a long cotton-carrier curved at the rough- 
ened end so that it is impossible for the pledget to drop off into the 
throat. This is dipped into the fluid and pressed against the side of 
the small container, which should have a wide mouth. After press- 
ing out all the surplus so that none will squeeze out and run down into 
the larynx, the medicated cotton is brought into contact with all the 
surfaces of the false membrane, making sure that the latter is wet 
with the sulphocalcin. The cotton is then burned. This treatment is 
repeated as often as is necessary to keep the membrane dissolved and 
the throat clear of it. At first it has sometimes been necessary to have 
the nurse apply it every fifteen minutes, lengthening the time be- 
tween the treatments, as the membrane becomes less rapidly formed, 
to a half-hour, an hour, or two or four hours. When no false mem- 
brane reappears the remedy is discontinued. The solvent effect of 
this treatment is so apparent that I wonder at its not having come 
into more general use. Its disagreeable odor is an unfortunate fea- 
ture. John Xorth informs me that a 30-grain solution of perman- 
ganate of potassium will dissolve the false membrane. 



1S2 TREATMENT OF DIPHTHERIA. 

In the British Medical Journal the lamented Lennox Browne 
spoke of sulphurous acid as being an efficient germicide that acts 
systemically as well as locally w r ith good results. I have often ap- 
plied the sulphocalcin pure, and always do when the false membrane 
is thick enough to prevent the remedy from coming into actual con- 
tact with the mucous surface; but, when the exudate is reduced to 
such a state of thinness as to allow the drug to penetrate to the mu- 
cous membrane beneath, it is necessary to dilute it with water until 
the smarting and burning otherwise produced is reduced to the point 
of toleration. Bat, the stronger it can be borne, the better the 
results. 

Hydrozone, or dioxide of hydrogen (peroxide, H 2 2 ), has proved 
very effective when it could be used in full strength with an atomizer. 
I have used large quantities of hydrozone during the past few years 
with great satisfaction. It is one of the best of disinfectants and 
antiseptics. When a spray of the fifteen-volume strength is made to 
copiously cover the false membrane it immediately begins to foam. 
As it comes in contact with pus-corpuscles they are decomposed and 
oxygen is liberated to destroy the micro-organisms present. The 
mechanical eifect of the process of effervescence appears to make the 
false membrane more friable, to loosen it, and to aid in its removal. 
It is best to spray an abundance of the fresh preparation into the 
throat while the tongue is depressed, so as to reach every part of the 
pharynx. Then the patient, if old enough, is directed to hold it in 
the throat and gargle it so that contact is prolonged. Gagging should 
be avoided for fear of producing vomiting and the loss of much- 
needed food. The tongue-depressor must not be carried far enough 
back on the base of the tongue to cause retching. This treatment has 
proved very effective in my experience, and is repeated every half- 
hour, or every one, two, or four hours, as the conditions demand. It 
is of prime importance that the hydrozone be strictly pure, fresh, and 
just opened, and not allowed to be exposed to the air, heat, or light. 
If the pure hydrozone cause too much smarting, it can be diluted. 

For some years before sulphocalcin and hydrozone were intro- 
duced I used lactic acid in a steam-atomizer. It appeared to have a 
beneficial action in softening and loosening the false membrane. It 
was a favorite remedy with Lennox Browne, who applied it pure once 
or twice a day and had the aurse make applications of a dilution, 1 
to 6, every two or three hours. It is to be pressed into the false mem- 
brane with a cotton swab. This cotton-applicator should always be 



TREATMENT OP DIPHTHERIA. 183 

used instead of a brush, for the latter is sometimes laid aside and 
forgotten only to be used at some future time and add more sorrow 
and deaths to the account of diphtheria. Such instances are on rec- 
ord. When pieces of the diphtheric membrane are macerated in pure 
lactic acid outside of the body it becomes "soft, translucent, and jelly- 
like." 

There is one objection to all applications that must be made with 
swab, brush, probang, etc. In the case of fighting, struggling chil- 
dren these methods probably do more harm than good by exhausting 
the little patient's strength. 

I have used the purple, or blue, pyoktanin, but am not satisfied 
of its value. From my experience with a 10-per-cent. solution of 
carbolic acid in glycerin in other diseases I am led to believe that 
its germicidal and local-angesthetic effects would be valuable here. 
Lime-water irrigations and sprays have but little effect on the false 
membrane, but the direct fumes of slaking lime are beneficial, as even 
steam alone tends to soften and loosen the membrane. The lime- 
water makes the membrane more friable, but not thinner. I could 
never see any satisfactory results from potassium chlorate except sim- 
ply as a cleansing solution. Salicylic acid is highly recommended by 
some Europeans, but is not in favor with Americans as a local remedy. 
I have no experience with it in diphtheria, but the results of trials 
with it for similar purposes in other diseases are not reassuring. In- 
sufflations of powdered sulphur are much used by the laity, but I have 
seen no benefit, though much misery, from them. 

Tearing off the pseudomembrane and cauterizing the mucous 
membrane is to be deprecated. Its forcible removal is justifiable only 
when it amounts to an actual obstruction to respiration. It should 
be borne in mind that the bacilli are not in the layer next to the mu- 
cous membrane, but in the superficial layers. Generally they are not 
found to have penetrated to the mucous membrane, — a fact that 
seems to have been lost sight of by those physicians who aim to pene- 
trate the deeper layer of the false membrane in order to inject reme- 
dies into the mucous tissues beneath, which opens up an avenue for 
the penetration of germs to the blood- and lymphatic vessels. 

J. Lewis Smith reported excellent results from the following 

prescription for topical application: — 

IJ Acidi carbolici, gtt. x. 

Liq. ferri subsulphatis, ..... f3iij. 

Glycerini, f3j- 

Aquse purae, . . f§ij. 



184 TREATMENT OF DIPHTHERIA. 

Loftier (Deutsch. med. Woch., October 18, 1894) gave to the Buda- 
pest Congress his formula for toluol for the local treatment of diph- 
theria. It consists of alcohol, turpentine, and 2-per-cent. phenol 
(proportions not given). Since then he has used the following for- 
mula: Alcohol, 60 volumes; toluol, 36; liq. ferri chloridi, 4. In 71 
cases in private practice he had no deaths; adding 30 cases in hos- 
pital with 5 deaths makes a mortality of 4.9 per cent. 

The local applications of toluol "should be begun early, should 
be thorough, and should be repeated- every three or four hours until 
the temperature sinks to normal, which usually occurs in from twenty- 
four to forty-eight hours. Af tenvard three times daily and continued 
as long as any membrane is present." 

Loftier claims that if this application is used often enough and 
thoroughly the disease does not spread and has not invaded the nose 
or larynx in any case so treated. Intense pain followed the applica- 
tion, so "20 volumes of menthol were added, making: menthol, 20 
volumes; toluol, 36; absolute alcohol, 60; liq. ferri chloridi, 4." 

When the nose is invaded, a spray of dioxide of hydrogen, 1 
part in 5 or 10, if it smarts, or Dobell's alkaline antiseptic solution, 
the formula for which is given in the appendix, should be sprayed 
into the nose until it is cleansed. Then the nares are cleared by 
blowing or by cotton on the small carrier (Fig. 115), and aristol is in- 
sufflated by means of the small powder-blower (Fig. 83). 

Cold applied continuously to the throat with icebags (Fig. 194) 
retards and modifies the intensity of the inflammatory action of the 
first stage, but, after the false membrane begins to separate, con- 
tinuous heat is indicated. The hot applications may be better borne 
than the ice in the first stage, and if the cold appear to produce much 
discomfort and irritation the heat should be substituted therefor. 
Water as hot as can be comfortably borne may be used in the same 
rubber bags. 

Acids retard the proliferation of micro-organisms, and for that 
reason lemon-water and cold water acidulated with the acid phosphate 
or dilute sulphuric acid are of service and grateful to the patient. 
If the sulphuric acid is used it must be taken through a glass tube 
and must not be allowed to come in contact with the teeth on account 
of its deleterious action on the enamel. Frozen milk and beef-tea 
cool the throat, quench the thirst, ami support the strength. Barley- 
and rice- water arc to In 1 recommended in the same way and lor the 
same reasons. 






INTERNAL TREATMENT OF DIPHTHERIA. 185 

Internal Treatment. — The patient should be persuaded to take 
milk in preference to water for quenching the thirst and for the sake 
of maintaining the strength. Insistence may need to be resorted to 
for the sufferers good. When the strength begins to wane alcoholic 
stimulants are necessary to bridge over the period of exhaustion and 
consequent collapse. Whisky, sherry-wine, or diluted alcohol in emer- 
gencies are generally to be preferred. Stimulation and alimentation 
by enemata may be required when swallowing is impossible or the 
stomach rejects everything. Preparations of predigested foods, pep- 
tonized meat, etc., can be injected into the bowel per rectum through 
a large catheter extending well up toward the sigmoid flexure. 

Tonics are indispensable in severe cases. Quinine and iron are 
the favorites of most physicians' unless heart-failure is impending, 
when strychnine is employed. Tincture of the chloride of iron is 
given in large doses every two hours, proportioned to the patient's 
age. It is best combined with glycerin, as, for example, in Billing- 
ton's formula: ^ Tincturse ferri chloridi, foj; glycerini, aquse, of 
each, f§j. Mercury in the form of the bichloride and the mild chlo- 
ride has for a long time been in high repute with the profession both 
in Europe and America. The corrosive sublimate is used in solution — 
1 to 10,000 — locally, and considerable doses in the form of pills, etc., 
are also given internally. The calomel is administered internally and 
by sublimation. Internally it is given in doses of 1 / 2 to 3 grains 
every two hours until the bowels move freely, and then the doses are 
placed at sufficient intervals to not weaken the patient by catharsis. 
When the membrane is discharged, the calomel is discontinued. I. 
"N. Love used sodium benzoate in doses of 5 to 15 grains. Guttmann 
and others claim good results from pilocarpine, but its depressant 
action on the heart and the bronchorrhcea it produces render its effi- 
cacy at least questionable in a disease with a natural tendency to 
heart-failure and respiratory obstruction. In case of enfeebled heart- 
action full doses of strychnia are indicated. 

Treatment for laryngeal invasion will be found in the division 
on the larynx (page 271). 

Apartments occupied by-diphtheric patients must always be thor- 
oughly fumigated with sulphur as soon as recovery takes place. Dry 
fumigation is not sufficient. In order effectually to destroy disease 
germs the air must be kept moist during the process of fumigation. 

Paralysis of the larynx, pharynx, velum palati, and lower ex- 
tremities and loss of the tendon reflexes are sequels of diphtheria. 



186 INTERNAL TREATMENT OF DIPHTHERIA. 

Strychnine in large doses, especially subcutaneously injected; cen- 
tral galvanization; and local faradization have given the best results 
in overcoming these paralyses. 

The antitoxin, or blood-serum, therapy, already mentioned, is 
considered in the following chapter. 

Intubation is treated of under a separate heading (page 273). 






CHAPTER XY. 

DISEASES OF THE PHARYNX (Continued). 
Diphtheria (Concluded). 

SERUM-THEEAPY IN" DIPHTHERIA. 

Behring, Kitasato, Koux, Ehrlich, Martin, and others have 
found, as a result of their experiments, that if the blood-serum of 
animals that have been deprived of susceptibility to a certain dis- 
ease be injected into other animals, it deprives the latter, in turn, 
of susceptibility to that disease, and modifies or aborts the disease if 
it be already present. Eabbits and guinea-pigs are employed in these 
experiments. If the serum from one of these animals previously 
immunized against diphtheria or tetanus be injected into another 
susceptible one, the latter is protected from the disease for a time. 

The method of procedure is these experiments is, briefly, as fol- 
lows: Enough of the poisonous product of the disease is injected into 
an animal to sicken it, but not to cause death. Small hypodermic 
injections of diphtheria cultures and toxins are given at first and 
gradually they are increased as the tolerance of the animal increases. 
As this process proceeds the blood of the injected animal acquires 
gradually increasing immunizing powers. The injections are fol- 
lowed by local tumefaction and fever. At intervals a quantity of 
blood is taken for the purpose of experimental tests on other animals 
to determine its efficacy. After the latter is shown to be sufficient, a 
large amount of blood is taken from the animal, placed in vessels on 
ice to produce coagulation, and the separated serum, mixed with 1 / 2 
of 1 per cent, of carbolic acid, constitutes the serum remedy. On 
account of their susceptibility and size, goats and horses are em- 
ployed to obtain this serum in large quantities. An enormous amount 
of this is produced in Germany. Behring says: "The works can now 
supply one hundred thousand doses a month, which barely keeps pace 
with the demand from Europe and America." 

The benefit to be derived from the antitoxin injection depends 
largely upon the time in the history of the disease at which the 
remedy is employed. If three or four days or a longer time has 

(187) 



188 SERUM-THERAPY IN DIPHTHERIA. 

elapsed, so that the disease has invaded the larynx or bronchial tubes, 
and the profound toxic effects of the diphtheric poison are mani- 
fested in the heart, nothing may save. If the building is nearly con- 
sumed by fire, water cannot save it. However, the patient should 
always be given the benefit of a doubt and the remedy that promises 
the most hope must be used. 

The German physicians report a large saving of life by the use 
of the serum-therapy. Eoux, of Paris, claims similar results. It is 
asserted that the serum itself is harmless, and some deaths that have 
followed immediately upon the injections may have been due to other 
causes, such as the syringe penetrating a vein and injecting air, or 
heart-failure, etc. Other deaths may have been caused by the acci- 
dental introduction of some other material of a septic nature. The 
varying results apparent in the statistics of different observers and 
hospitals are likely affected to a considerable extent by a difference 
in the virulence of the several epidemics and of different cases in the 
same epidemic. 

The serum injections are made in the loose subcutaneous tissue, 
generally below the axilla or between the shoulder-blades, after pre- 
paring the skin by washing with soap and a bichloride solution, 1 to 
1000. The antitoxin of Behring comes in hermetically sealed flasks or 
vials bearing labels that indicate the doses contained. Each vial 
contains one dose, as follows: No. 1, 600 immunizing units, to be 
used on the first or second day of the attack; No. 2, 1000 units, for 
serious cases on first or second day or in mild cases of longer dura- 
tion; No. 3, 1500 units, for adults or severe cases in children. If 
one injection does not prove effective, it is repeated after twenty-four 
hours. 

As a prophylactic, smaller doses are given. For children, 100 to 
200 units are sufficient. The length of time this dose affords im- 
munity is not definitely known, but it is safest not to allow more than 
three weeks to elapse with a chjld still exposed to the disease without 
a repetition of the protective dose. 

We will now consider the results of the blood-serum therapy. 

"Professor Behring delivered a recent address on this subject in 
which he replied to the swarms of critics who have been attacking him 
the past year or so. He maintained that statistics prove the efficacy 
of the serum, and that the 60,000 deaths from diphtheria which the 
German empire lias averaged each year will be found to be reduced 
to 40,000, and a more general use of the serum would reduce this to 



SERUM-THERAPY IN" DIPHTHERIA. 189 

one-third. Throughout the city of Berlin the fatality in diphtheria 
amounted to 30 per cent., but in the Contagions Hospital, where 
serum was promptly used, the mortality was only 20 per cent. In 
the same time in 1895 it was only 10.3 per cent. The mortality in 
the hospitals had always been much greater than outside heretofore. 
Last year the percentage of mortality in diphtheria cases in Berlin fell 
to 15 per cent. During this period the disease was not a mild form, 
but averaged more morbid symptoms than at any time since 1886. 
During the first three months of 1894, when the serum was not to 
be had, there were 363 deaths per 1000, while the last three months, 
when everybody could get the serum, there were 198 deaths per 
1000." 

"Kossel, speaking for Koch' and of the results obtained in the 
Institute for Infectious Diseases at Berlin, declares that no uncom- 
plicated case that was treated in the first or second stage of the disease 
was lost, and that the mortality of all cases was reduced to 16 per 
cent." (Sajous's "Annual of the Universal Medical Sciences.") 

The use of antitoxin is highly extolled by the French. M. Monod 
claims that its use has decreased the mortality from diphtheria 65 
per cent., and it is claimed that by its use 15,000 lives have been saved 
in France. 

As to the effects of the serum on the course of the disease, ac- 
cording to the experience of Dr. Kitasato, of Japan, the points to be 
noted are: "1. The fall of temperature; in many cases the defer- 
vescence was almost critical, and it takes place usually at the end of 
from twenty-four to forty-eight hours. 2. The separation of the false 
membrane, which takes place, as a rule, after the return of the tem- 
perature to near the normal. Very large casts of the trachea and 
larger bronchi have been coughed up. 3. Urticaria-like eruptions were 
observed in very many cases, being, in some, quite severe and annoy- 
ing. They, however, disappeared in a few days without any treat- 
ment. 4. In 4 cases marked albuminuria was observed at the time 
of admission. In these cases albumin disappeared from the urine in 
the course of the treatment. Pyrexia was accompanied by albumin in 
the urine, but there was no reason to believe that any renal trouble 
was caused by the injections. 5. Five cases developed paresis of the 
soft palate. Microscopical as well as culture examinations were made 
in every case, and Dr. Kitasato's report of 26,521 cases deals with 
those cases only in which Loffler^s bacilli were demonstrated to be 
present." (Journal of the American Medical Association.) 






190 SERUM-THERAPY IN DIPHTHERIA. 

Eegarding the accidents following injections of antitoxin, and 
referring to the death of Professor Langerhans's child, Edwin Klebs, 
late Professor of Pathology in the Chicago Post-graduate Medical 
School, says: "The good effect (of serum-therapy) in the first two 
days of diphtheria seems to be doubtless." Eeferring to the Atlanta 
meeting of the American Medical Association, he continues: "I 
remarked the dangerous effects in some rare cases, as that of Pro- 
fessor Langerhans. Xow the papers bring the notice that the death 
occurred by the introduction of stomach-contents in the bronchi. I 
do not know if that is acceptable, possibly post-mortal. I wished to 
point out the problem to get the antitoxin substances in a purer form, 
so that all possibility of infection may be avoided.'* In his discussion 
at the meeting referred to, Professor Klebs said: "Xow I come to a 
point that seems to me to be of the highest importance, — the danger 
of antitoxin. I wish that point would be illustrated in a more ex- 
tensive manner by publishing all cases in which the injection was 
shortly followed by death. We have such cases, but a part of them 
seems to be on account of the disease. But if in one case alone the pa- 
tient has been killed by antitoxin, we have a great interest to find out 
the true cause of the death. Such a case is that of Professor Langer- 
hans, in Berlin. After a girl in the house became diphtheric, he 
thought he would, if possible, prevent the spreading of the disease to 
his own children; but after the injection the first child died immedi- 
ately. So it is possible that death may occur after the most cautious 
injection of antitoxin, — a fact that gives a high responsibility to every 
physician using this remedy. We must search, therefore, to find out 
what may have been the cause of such fatal accident. 

"In this case it is reported that the body of the dead child was 
quite normal, well nourished. There was no introduction of air into 
the blood. The clanger of introducing air is, by the way, not so great 
as often accepted. One can inject some centimetres of air in the 
blood-vessels of a rabbit without any bad effect, as the air is resorbed 
in a very short time. It will be better to inject the fluid in children 
into the muscles far distant from the lungs, — the dorsal or gluteal 
region. Then it is convenient to push the needle alone in first and 
see if bleeding follows or not. If not, one may inject without fear, 
but always slowly, under no high pressure. If these precaution- arc 
followed, I think that no danger can be feared from the injection. 

"I think it is not probable thai the antitoxic serum itself con- 
tains such a formidable heart-poison, as very great quantities of it 



SERUM-THERAPY IN DIPHTHERIA. 191 

injected into the peritoneal cavity of animals prove harmless. Much 
more probable it seems to me, that in this and other similar cases 
observed in Brookl}'n, N". Y., an accidental pollution of the antitoxin 
has combined with intravenous injection to produce fatal effect. 

"The sure disinfection of serum is a very difficult matter. Twice 
I have found microbes in tubercle serum. On the other side, the best 
antiseptics — as mercury bichloride, phenol, and kresol — make coagu- 
lations in the serum. Therefore, one must search for other disin- 
fectants that will not coagulate albuminous matters. I note that 
chinosol is proclaimed as such by Emmerich; its antiseptic action is 
forty times stronger than carbolic acid and it does not coagulate 
albumin. I have proved it a very good disinfectant for external and 
internal use, and I would recommend it for the disinfection of serum. 
Certainly we must demand from the manufacturers of antitoxic serum 
that they must prepare the serum in an absolutely pure manner, ex- 
cluding totally the possibility of accidental pollution. It is not a good 
manner to dispense it in colored bottles. It can be protected against 
the light by .dark coverings. 

"I am sure that all these precautions can be executed and will be 
executed in this land, in which I have seen as good bacteriological 
work as anywhere in Europe/' 

In another letter, dated December 1, 1897, Professor Klebs 
writes, among other things: "My opinion is that we must have the 
antitoxins from the cultures and that we need not use more serum." 
He refers to a paper which he read at the meeting of the American 
Medical Association in 1897, in which he states that "In the serum 
there must be contained not only antitoxic, but also bactericidal, prin- 
ciples. It is, therefore, most probable that not only antitoxic, but 
also bactericidal, principles work together to produce the curative 
effect of the serum. Furthermore, these bodies are not new products 
formed in the immunized animal, but transformed from the injected 
culture-fluid. This leads to the possibility that we are able to trans- 
form the culture as such directly, without the passage through the 
body of an animal, and my experiments in this line seem to emphasize 
this theory." 

In the case of the sudden death of Professor Langerhans's child, 
the official report says "that previous to the fatal injection the child 
had taken dinner, followed shortly afterward by some milk and cake. 
Death took place during a severe fit of coughing, and the necropsy 
showed that the trachea and bronchi were entirely filled with a gray 



192 SERUM-THERAPY IN DIPHTHERIA. 

substance, which was proved by microscopical examination to consist 
of particles of food, a good deal of the same being still present in the 
stomach. The uvula was swollen. The medical experts declare, there- 
fore, that the child died from suffocation. They are of the opinion 
that the boy vomited after the injection, and that, being in a fainting 
state from the pain of the injection, he was not able to get rid of the 
vomited matter, but drew it into the larynx in the act of inspiration. 
They did not find any embolus of air in the pulmonary artery, as was 
suggested, nor was there any confirmation of the opinion that death 
had occurred by syncope. According to the statement of the Control 
Office, the serum was of normal quality." 

The medical press in November, 1901, reported 20 cases of tet- 
anus, with 13 deaths, in St. Louis, attributed to diphtheria antitoxin 
prepared by the Health Department of that city. A large horse had 
been under treatment for the production of antitoxin for nearly three 
years, had been bled a number of times, and had furnished over 30,000 
cubic centimetres (30 quarts) of the antitoxin. The greater part of 
the antitoxin distributed by the Health Department during the years 
1900 and 1901 came from this horse. On October 2d the horse was 
taken sick with tetanus and was killed. The last serum was taken 
from him on September 30th, and the first of the series of tetanus 
cases, which resulted from the use of his serum, was reported on 
October 26th, 1901. 

At the coroner's inquest on the deaths mentioned above, the as- 
sistant bacteriologist of St. Louis testified that "the infected diph- 
theria antitoxin used was not tested on guinea-pigs before its distribu- 
tion by the department. The serum was intrusted to a negro janitor 
in the city chemist's office; some of the bottles were not labeled, and 
the janitor was the only person who could distinguish them." 

Great vigilance should be exercised by the bacteriologists who are 
charged with such a responsible trust. In the Health Department of 
Chicago all of the antitoxin used or distributed by its members is 
tested. "Out of each installment received in the laboratory, 5 per 
cent, is tested on guinea-pigs previously injected with diphtheria 
toxin; if the animals survive without untoward symptoms or undue 
reaction, the installment is accepted as of the antitoxic strength indi- 
cated on the label of the package. Obviously, if the serum contained 
the tetanus bacillus or other pathogenic germ, that fact would be 
developed in the test. No such result has ever followed during the 
six years' use of this remedy by the department, but on three occa- 



SERUM-THERAPY IN DIPHTHERIA. 193 

sions installments have been rejected for failure of the indicated anti- 
toxic strength." {Journal of the American Medical Association, No- 
vember 23, 1901.) 

Eeports of health commissioners of various cities give the results 
of the serum-therapy as follow: In New York City the death-rate 
was reduced by antitoxin from an average of 33.93 to 21.16 per cent.; 
Indianapolis, from 26.29 to 13.36 per cent.; St. Louis, in 1894, with 
no antitoxin, the death-rate was 28.2 per cent.; in 1895 the death- 
rate among those treated with antitoxin was 8.4 per cent. The 
Chicago Health Department reported in May, 1896, a reduction from 
52 to 9 per cent.; Boston, from 50 to 16. The Kaiser and Kaiserin 
Hospital, of Berlin, reports a reduction from 50 to 10 per cent., and 
the Willard Parker Hospital shows a mortality of only 10 per cent, 
under serum-therapy (New York Medical Journal). In the Boston 
City Hospital the reduction in the death-rate was from 42 to 17 per 
cent. In the Johns Hopkins Hospital Bulletin W. H. Welch shows 
that, in 814 cases in which the serum was used before the third day, 
the percentage of deaths was only 5.5 per cent. 

Dr. Arthur E. Eeynolds, Commissioner of Health of the City 
of Chicago, wrote to me under date of November 13, 1897, as fol- 
lows : — 

"Answering your queries concerning the antitoxin treatment of 
diphtheria by the Chicago Department of Health, I submit the fol- 
lowing: — 

"1. Since October 5, 1895, when this treatment was begun by 
the department, and up to the close of last month, October 31, 1897, 
a total of 4658 cases of alleged diphtheria were reported to the de- 
partment for investigation and treatment. Of this number 3982 cases 
were bacterially verified as true diphtheria, and in 3759 cases the 
antitoxin was permitted to be used, with the following results: — 

Total cases treated 3759 

Total cases recovered 3514 

Total cases died 245 

Death-rate, 6.51 per cent. 

"Among those treated subsequently to March 31, 1896 — records 
of intubations prior to that date are imperfect — there were 145 in- 
tubations, with 121 recoveries and 24 deaths. Death-rate of intubated 
cases, 16.53 per cent. 

'There were also treated with immunizing doses of antitoxin 



CiT 

xiieit; weic aiau ucaicu w 

13 



194 



SERUM-THERAPY IN DIPHTHERIA. 



2631 cases of persons exposed in infected families, of which number 
16 were subsequently attacked with the disease, but all recovered. 

"As bearing upon the question of treatment with relation to age 
of patient and reported day of disease when first antitoxinized, the 
following are the figures of 1391 cases treated during the last twelve 
months— November 1, 1896, to October 31, 1897:— 



Eesults of Antitoxin Treatment 


in Bacteeially Veeified Diphtheria. 


Day of Disease 

when First 

Treated. 


Totals, by Ages. 


Recovered, by Ages. 


Died, by Ages. 




i 

Under! 1 to 5 
1 year.! years. 


5 to 10 

years. 


Over 
10 yrs. 


Under 
1 year. 


lto5 

years. 


5 to 10 
years. 


Over 
10 yrs. 


Under 
1 year. 


1 to 5 

years. 


5 to 10 

years. 


Over 
10 yrs. 


First day . . . 


26 


76 


54 


33 


26 


75 


54 


33 





1 








Second day . . 


45 


155 


112 


71 


41 


153 


110 


71 


4 


2 


2 





Third day . . . 


32 168 


120 


77 


31 


157 


113 


73 


1 


11 


7 


4 


Fourth day . . 


32 


97 


60 


45 


30 


89 


58 


42 


2 


8 


2 


3 


Later than 
fourth day . 


20 


74 


61 


33 


11 


57 


50 


25 


9 


17 


11 


8 


Totals 


155 


570 


407 


259 


139 


531 


385 


244 


16 


39 


22 


15 



"There were 92 deaths in the 1391 cases treated: a mortality- 
rate of 6.61 per cent. 

"With reference to reported day of disease when first treated, 
there were 189 treated on the first day, with 1 death: mortality-rate, 
0.53 per cent.; 383 on second day, with 8 deaths: mortality-rate, 
2.06 per cent.; 397 on third day, with 23 deaths: mortality-rate, 
5.79 per cent.; 234 on fourth day, with 15 deaths: mortality-rate. 
6.41 per cent.; and 188 first treated later than the fourth day of the 
disease, with 45 deaths: a mortality-rate of 23.92 per cent." 

Since Eeynolds introduced the use of antitoxin in the Health 
Department of Chicago in 1895 the productions of Behring; Roux; 
Parke, Davis and Company; Mulford, and others have been employed. 
Four grades are now used, as follow: — 

Grade No. 3 A. — Vials contain 5 cubic centimetres, 150 anti- 
toxin units (Behring's standard) to each cubic centimetre, or 750 
units. 

Grade No. 4. — Vials contain 5 cubic centimetres, 200 antitoxin 
units (Behring's standard) to each cubic centimetre, or 1000 units. 



SERUM-THEKAPY IN DIPHTHERIA. 195 

Grade No. 5. — Yials contain 5 cubic centimetres, 300 antitoxin 
units (Behring's standard) to each cubic centimetre, or 1500 units. 

Grade No. 6. — Yials contain 5 cubic centimetres, 400 antitoxin 
units (Behring's standard) to each cubic centimetre, or 2000 units. 

The department has issued a circular of information, which con- 
tains such important advice, of practical value, that we will quote 
briefly from it: "It is apparent that preparations of antitoxic serum 
which contain a large amount of antitoxin to each cubic centimetre 
are more desirable than those containing a smaller amount, since the 
dose required is proportionately less, and disagreeable symptoms, 
which sometimes follow injections of the larger quantity of the 
weaker serums, will be avoided. The highest-grade preparations, how- 
ever, are much more difficult to produce, are necessarily more ex- 
pensive, and at present, even with approved [improved?] methods, 
can be produced only in limited quantities. 

"The average curative dose of diphtheria antitoxin is about one 
thousand (1000) units; but for very severe cases, or croup cases, or 
those in which the serum is not administered until the third day or 
later, fifteen hundred (1500) or two thousand (2000) units are often 
required, and sometimes the dose must be repeated; so that altogether 
from four to six thousand units may be required in a single case. Full 
directions as to the use of the serum accompany each vial. 

"From one hundred (100) to three hundred (300) units, accord- 
ing to age, are required to confer immunity. The immunity thus 
produced ordinarily lasts for a period of at least four weeks. With 
the new and strongest preparations of antitoxic serum, only very small 
quantities of the serum (from 6 to 15 minims) are necessary for the 
production of immunity/' 

The Health Department reports that no serious symptoms have 
resulted from the antitoxin itself: "There have been some local pain 
at the seat of the injection (just above the crest of the ilium), some 
swelling and redness, urticaria following from three to ten days after 
its use, but in no case were the sequels one-half so painful or so 
formidable as the mildest sequences of successful vaccination. There 
have been a few cases of albuminuria a few days after the use of 
immunizing doses of antitoxin, but these have been very transitory 
and soon pass away, with complete recovery — never any serious con- 
sequences; while, in all cases of marked albuminuria resulting from 
diphtheria, the renal symptoms rapidly subside after the administra- 
tion of antitoxin of the proper strength and quantity. Albuminuria 



196 SERUM-THERAPY IN DIPHTHERIA. 

from antitoxin has not been observed since we have been using the 
higher powers of antitoxin with smaller amounts of serum. jSTot only 
that, but careful experimentation has convinced us that albuminuria 
came from the large use of the serum and not from the antitoxin 
itself, and the same may be said of other sequels. The effect upon the 
diphtheric infection is most remarkable: at once arresting the disease 
if used in the early stages and properly administered, and giving ex- 
cellent results even when used after the fourth day, although this 
cannot be so confidently expected as when the antitoxin is used early." 

The use of antitoxin in the Cook County Hospital, Chicago, was 
begun in July, 1895, and was continued under the charge of D. D. 
Bishop, W. L. Baum, and A. C. Cotton. The results were published 
by H. A. Brennecke, who says: "According to the various statistics, 
the mortality of diphtheria before the use of the serum is placed at 
about 40 per cent. Since the serum has been used in the Cook County 
Hospital the mortality, as is shown by the tables, has been reduced to 
12.5 per cent." (Medicine, January, 1898.) 

The following letter was in reply to a request for the results of 
the antitoxin treatment of diphtheria by the health officers of Chi- 
cago: — 

C/^y of Lshicago 

^Department of ZHealth 



Arthur R. Reynolds, M.D. 

COMMISSIONER 

Seth Scott Bishop, M.D., 



February 13, 1903. 



Chicago. 



Dear Sir: 

Accompanying this please find, in response to your request for the pres- 
ent percentage of mortality in diphtheria treated by the Medical Inspectors 
of the Chicago Health Department, a copy of the January, 1901, Bulletin, 
which gives in detail the results in the treatment of 5727 cases of bacteriallv 
verified diphtheria between October 5, 1895, and December 31, 1900, with a 
mortality of 6.79 per cent. 

To these should be added 557 cases treated in 1901, with 35 deaths, and 
039 cases treated last year (1902) with 26 deaths, making a total of 0923 con- 
secutive cases of true diphtheria — bacterially verified as such — during 87 con- 
secutive months, with a total of 450 deaths, making a death-rate of 6.49 per 
cent. 

Of the gross total, 673 were laryngeal diphtheria requiring intubation, 
and 192 of these died: a mortality-rate of 28.52 per cent, of intubations. 



SERUM-THERAPY IN" DIPHTHERIA. 197 

Of the total 639 eases treated last year, with a mortality-rate of 4.06 
per cent., 50 required intubation, and 12 of these died: a mortality-rate of 24 
per cent, of the intubated, and of 4.12 per cent, of the remaining cases. 
Trusting these figures may serve your purpose, I am, 

Faithfully yours, 

Arthur E. Reynolds. 

A critical review of the great mass of evidence accumulated, both 
favorable and unfavorable, to the blood-serum therapy, a small frac- 
tion of which is here presented, forces the conclusion that the pre- 
ponderance of evidence justifies the verdict that diphtheria antitoxin, 
administered early and in sufficient doses, — the first or second or not 
later than the third day of the disease, has the power to prevent a 
fatal issue. Given later it may modify the intensity of the toxaemia 
if a multiple of the ordinary dose be given. 

Mixed infection, and invasion of the larynx demanding intuba- 
tion or tracheotomy, lessen the chances of recovery. 

While the serum is a powerful remedy and may be capable of 
doing harm, the disease itself is so virulent that, in view of the great 
weight of testimony and statistics in favor of the antitoxin, the phy- 
sician should not fail to avail himself of this addition to thorough 
local and general treatment. 



CHAPTEE XYI. 
DISEASES OF THE PHARYNX (Continued). 

Tonsillitis. 

TJndek this heading it is convenient to treat of acute inflamma- 
tion of the tonsil and of the peritonsillar tissue. 

Synonyms. — Quinsy; amygdalitis; phlegmonous sore throat; 
angina tonsillaris; ulcerative tonsillitis; suppurative tonsillitis; ab- 
scess of the tonsil. 

Pathology. — This is an acute inflammation of one or both tonsils. 
There are three principal varieties: (1) simple catarrh, (2) ulcerative 
tonsillitis, and (3) abscess of the tonsil. 

Some authorities distinguish five varieties of this disease, but 
practically they are all variations of three types of inflammation. 
The inflammatory action may be of a mild catarrhal character and 
limited to the mucous membrane, or it may eventuate in superficial 
ulceration, or it extends to the submucous tissues, with infiltration 
of the whole gland and the peritonsillar connective tissue. In the 
second and third forms the lacunae, or crypts that indent the surface 
of the tonsil, are filled with micrococci, pus, and epithelium. 

Tonsillitis is most frequent in persons between the ages of 15 and 
30 years, and especially among those of a rheumatic habit and with 
hypertrophied tonsils. The inflammation usually involves to a 
greater or less degree the pillars of the fauces and uvula. They are 
red and swollen and the uvula elongated and troublesome (Plate III). 
The attack may terminate in resolution, ulceration, abscess, or hyper- 
trophy. In the case of an abscess it may rupture near the superior 
and anterior portion of the tonsil in the vicinity of the arch of the 
soft palate. The orifices of the crypts may become obstructed, with 
the result of distending these cavities with the pent-up secretions. 

With regard to the bacteriology of tonsillitis, it cannot be said, 
at the present time, that the various forms of tonsillitis are caused by 
any special organism, although they may be traced to a microbic in- 
fection. A. Veillon (Archives de Medecine, March, 1894) concludes 
that "pathogenic microbes may be found in all forms of non-diph- 
(198) 



TONSILLITIS. 199 

theric tonsillitis. The streptococcus pyogenes virulens was present 
in the twenty-four cases examined, and was usually associated with 
the less virulent pneumococci and sometimes with staphylococci. The 
streptococcus appears to play the most important role in all cases. 
The different kinds of tonsillitis are of the same nature. The clinical 
and anatomical differences depend upon (1) whether the organisms 
affect the surface of the mucous membrane, its deeper layers, or the 
subjacent cellular tissue, and (2) the virulence of the microbes and 
the resistance of the subject." 

Etiology. — While tonsillitis is not usually met with in persons 
younger than 15 or older than 30 years, I have seen it above the 
fiftieth year. No age is absolutely exempt. In my opinion, rheuma- 
tism is an important factor in the production of this disease. A close 
relationship is often observable between attacks of tonsillitis and 
rheumatism, one following or preceding the other — one subsiding as 
the other develops. Cold, damp, foggy, or changeable weather is a 
predisposing cause; the presence of hypertrophy and the history of 
previous attacks presage future ones. Unusual exposure is a frequent 
excitant of this as it is of other inflammations. The crypts are often 
found filled with caseous masses that excite inflammatory action. 
These cheesy plugs undergo decomposition and become acrid, irri- 
tating, and foul-smelling. Acute tonsillitis occasionally follows nasal 
cauterization. 

Symptomatology. — Premonitory symptoms are: a heavy feeling 
akin to exhaustion, followed by a sense of feverishness, headache, and 
pain in the back and legs. Chilliness may be present during the first 
few hours and the temperature may rise to 103° or 105° F. by the 
second day. If the fever is very high it indicates that the deeper 
structures are likely to become the seat of an abscess. As the disease 
progresses, the tonsil becomes swollen and obstructive to deglutition; 
sensations as if a foreign body were in the throat, together with 
increased secretion of mucus, occasion frequent efforts to free the 
throat by swallowing, which becomes more and more difficult. All the 
surrounding tissues may participate in the inflammation in the severe 
type so that the velum and uvula are red, thickened, and sensitive. 
The elongation of the uvula to the extent of constant contact with 
the tongue (Plate III) adds to the excitants of painful deglutition. 
When the inflammatory action extends to the orifices of the Eusta- 
chian tubes and to the pharyngeal tonsil, impaired hearing, noises, 
and even pain in the ears ensue. These symptoms represent the crisis 



200 TONSILLITIS. 

of the simple catarrhal form of a severe character, and now begins an 
abatement of the inflammation, subsidence of the pain, swelling, diffi- 
cult swallowing, and the membrane begins to assume a more natural 
color. 

In the second, or ulcerative, form, instead of an amelioration of 
all the symptoms at the crisis of the inflammation, the mucous mem- 
brane softens and breaks down in spots. The surface of the gland is 
dotted with small, yellowish-gray points (Plate III) that coalesce and 
form irregular ulcers covered with a muco-purulent discharge. I 
have known physicians to mistake this coating of the ulcers for a 
diphtheric exudate, but the deposit can be seen at first as limited to 
the orifices of the lacunae, and there is a wide difference between the 
two, even in macroseopical appearances. 

When the inflammation extends to the deeper structures speech 
is seriously interfered with, and it is difficult to articulate with suffi- 
cient clearness to be understood. The mouth cannot be opened on 
account of the pain and tumefaction about the angle of the jaw, and 
it may be well-nigh impossible to examine the pharynx, even with 
the aid of the forehead-mirror and tongue-depressor (Plate III). In 
this stage cold sweats and sleeplessness are sometimes experienced. 
Liquids regurgitate into the nose or find their way into the larynx, 
occasioning most violent fits of coughing and strangling. The cer- 
vical muscles sometimes become sore and tender on pressure. The 
continuous exertions necessary to clear the throat of secretions, which 
are not swallowed, but allowed to slaver from the mouth, serve to in- 
crease the distress. When the uvula can be seen, it is found clinging 
to the affected tonsil. While the secretion of saliva is increased, the 
urine is diminished in quantity and of high color. The breath be- 
comes freighted with a fetid odor and the tongue is furred with a yel- 
lowish-gray coat. The bowels are generally constipated. 

Mild attacks of tonsillitis may not extend beyond a week, but the 
severe form, which terminates in an abscess, is a tedious type. In 
the course of a week or ten days a chill denotes the formation of pus. 
and a little later, if the abscess is not opened, it breaks, usually in the 
throat. However, it may rupture externally at the angle of the jaw. 
or burrow underneath the cervical muscles, forming an abscess of the 
neck, or it may gravitate to the thoracic cavity. 

Diagnosis. — The characteristic symptoms described render the 
diagnosis comparatively easy. There is not much likelihood of con- 
founding this disease with any other but diphtheria. In the latter 



TONSILLITIS. 201 

disease the tonsils are not always swollen, and the false membrane is 
thick, leathery, and of much lighter color generally. Yet it must not 
be forgotten that the Klebs-Lofrler bacillus is sometimes found in the 
throat when there is no false membrane; so that in suspicious cases 
a bacteriological examination should be made. In the sore throat of 
measles and scarlet fever the distinguishing rash, the ease of opening 
the mouth, and the comparatively little enlargement of the tonsils 
clear up any doubt. Syphilitic sore throat does not present the in- 
tense group of symptoms of severe tonsillitis, and can be differentiated 
from the mild catarrhal form, in that fever and pain are generally 
absent and the difficulty of swallowing is not so prominent a symp- 
tom. Patches of redness, instead of the bright, diffused, red glow of 
acute tonsillitis, characterize the early stages of syphilis, while the 
secondary stage is manifest in the mucous patches and skin eruptions, 
and the tertiary stage in the deep ulcerations and an unmistakable 
history. 

Prognosis. — Simple catarrhal tonsillitis usually terminates in 
resolution, running a course of about a week. It is often preceded or 
followed by a rheumatic attack of other structures, and may end in 
tonsillar hypertrophy. Ulcerative tonsillitis also tends toward re- 
cover}', but the possibility of invasion of other parts, such as the 
Eustachian tubes and tympanic cavities, emphasizes the necessity for 
efficient treatment. Occasional deaths have occurred from tonsillar 
abscess emptying into the larynx or causing laryngeal oedema. The 
occurrence of an abscess lengthens the attack to two or three weeks 
and sometimes longer. 

Local Treatment. — Local applications of glycerin of tannin have 
proven effective in the simple catarrhal tonsillitis. I am aware of the 
opposition to this treatment by high authority (Lennox Browne), but 
one cannot ignore years of actual satisfactory experience with it. 
The writer has made it a practice to apply this remedy with a very 
soft, bushy camel's hair pencil every two or four hours. If there is 
considerable pain, a 10-per-cent. solution of carbolic acid in glycerin 
will afford a local anaesthetic effect, besides depleting the vessels and 
acting as an antiseptic. I have found local applications of guaiacol 
useful. It appears to shorten the attack. If the pure drug is painful, 
it can be diluted one-half with glycerin. Gargles of alum-water and 
potassium bromide in 4-per-cent. solutions are grateful in some cases. 
Much refreshing relief is experienced after copiously spraying the 
throat with benzoinated lavolin or a 3-per-cent. solution of camphor- 



202 TONSILLITIS. 

menthol (Figs. 11 and 12). The author's throat-tablets also have 
given excellent satisfaction. Each tablet contains the equivalent of 
the following formula: — 

Ifc Ammonii chloridi, gr. j. 

Tincturae opii camphoratse, 
Syrupi scillae compositi, 

Syrupi Tolutani, of each, min. v. 

Extracti glycyrrhizae, gr. iij. 

These are allowed to melt slowly in the month, so as to prolong 
the contact of the remedies as much as possible with the inflamed 
membrane. C. E. Bean recommends a compound rhatany lozenge, 
consisting of 2 grains of extract of rhatany, 1 / e grain of extract of 
opium, and 18 grains of currant-paste. 

Ulcerative tonsillitis should be treated with alkaline disinfectant 
and antiseptic topical applications. Frequent sprays of hydrozone, 
Dobell's and Seller's solutions, glycothymolin, listerin,- pasteurin, 
borolyptol, etc., will cleanse and disinfect the glands, after which a 
covering of aristol should be given with the powder-blower (Fig. 83). 
A 10-per-cent. solution of silver nitrate applied to the ulcerated sur- 
face hastens the cure. 

If an abscess is threatened by the severity of the symptoms, local 
cold should be used early by means of an icebag (Fig. 194) directly 
over the tonsil. As soon as an abscess can be discerned it should be 
opened instead of waiting for nature to accomplish this. Several days 
of extreme wretchedness will be spared the sufferer by this means. 
The knife should have a handle sufficiently long to not hamper one 
in his movements. The cutting edge must be kept toward the median 
line so as to avoid wounding the internal carotid artery, which might 
occur by a sudden movement of the patient if the cutting edge were 
directed toward the artery. The abscess usually points near the arch 
of the anterior faucial pillar. E. C. Myles injects a few drops- of a 
4-per-cent. solution of cocaine into the tissues before incising them 
(The Laryngoscope, February, 1898). 

For phlegmonous tonsillitis Gouguenheim (Lyon Medical, 1894) 
recommends Leiter's coil around the throat, leeches to the angle of 
the jaw, 20- to 33-per-cent. cocaine painted in the pharynx, irriga- 
tions with warm boric-acid solution, and salol or naphthol internally 
for an intestinal antiseptic. 

Tonsils that are subject to recurring attacks of inflammation 
should be guillotined (see division on "Tonsillotomy"). Kitchen ex- 



TONSILLITIS. 203 

rises the tonsil to abort an impending attack of quinsy, and to prevent 
future attacks. 

Constitutional Treatment. — When the pain is severe and swallow- 
ing difficult, I have seen the most gratifying relief attend the admin- 
istration of a combination of morphia with atropia in the proportion 
of 1 / 8 grain of morphia to 1 / 600 grain of atropia. This remedy relieves 
pain and irritability, checks the excessive secretions that constantly 
excite efforts to swallow, and modifies the intensity of the inflam- 
matory process. Patients to whom I have administered this for the 
first time, and who have been in the habit of passing through similar 
attacks for years, have remarked with unfeigned gratitude that they 
had never before received such relief from suffering during a siege of 
their malady. A laxative should be given at the onset of the attack, 
so as to open the bowels freely. Aconite enjoys quite a reputation 
in this disease, given in doses of 2 or 3 drops every half -hour. Potas- 
sium bromide, mentioned in connection with local treatment, has a 
beneficial sedative effect if some of it is swallowed after gargling with 
it, so that 10 grains every two or three hours are taken. 

The rheumatic character Of this affection calls for such remedies 
as salicylic acid and antipyrin. If there is no reason why salicylate of 
sodium should not be given, it is to be preferred. When it is well 
borne the writer gives 10 grains every two hours until the symptoms 
become ameliorated or slight physiological effects are produced. A 
freshly prepared solution should be used, for example, as follows:— 



I£ Acidi salicylici, 


3iij. 


Sodii bicarbonatis, 


3ij. 


Elixiris gaultherise, 


3ss. 


Glycerini, 


3iij. 


Aquae, 


. q. s. ad 3iv. 



Misce. Signa: One teaspoonful, in water, every two hours. 

If salicylate of soda disagrees with the stomach or causes ringing 
in the ears, salicin should be substituted in pilular form, 5 grains to 
be taken every two or four hours. 

Antipyrin in doses of 5 or 10 grains every three or four hours not 
only relieves pain, but possesses especial efficacy in rheumatic affec- 
tions. 

Salophen and salol, given in effective doses early in an attack, 
will subdue the inflammation and apparently prevent the formation of 
an abscess. They should be administered in 5- or 10-grain doses every 



204 HYPERTROPHY OF THE TONSILS. 

two to four hours, at first, according to the age of the patient and the 
severity of the attack. 

Hypertrophy of the Tonsils. 

Synonyms. — Enlarged tonsils; chronic tonsillitis; follicular ton- 
sillitis. 

Pathology. — Hypertrophy of the tonsils is a true hyperplasia, 
according to Virchow, in which all the glandular elements participate 
in the proliferous process. The increase and induration of the con- 
nective tissue is manifest in some tonsils at the time of excision, by 
the resistance to the passage of the guillotine through them, but in 
most instances they are yielding and sponge-like. The crypts are ex- 
panded and their walls are tumefied. Instead of a tenacious mucus 
filling the cavities there are often cheesy masses of a light-yellow color 
sometimes mixed with calcareous concretions. There is an increase 
in size and usually in number of the follicles surrounding the de- 
pressions. Norris Wolfenden (Journal of Laryngology, etc., August 
18, 1894) reports the results of studies in follicular tonsillitis as fol- 
low: "Follicular tonsillitis is a desquamative process in the crypts 
of the tonsils, the follicles taking no part in the process and only 
exhibiting a secondary hypertrophy, as recently maintained by Soko- 
lowski and others. There are other forms of infective tonsillitis 
associated with the exudation of fibrin, the presence of streptococci, 
staphylococci, and pneumococci." 

In the follicular, or lacunar, tonsillitis the pseudomembrane 
shows staphylococci and streptococci and the pseudodiphtheric ba- 
cillus. It cannot always be distinguished from diphtheria except by 
bacteriological examinations. 

Kriickmann (Virchow's Archiv) confirms Hanau and other ob- 
servers in the view that the tonsils are the portal of entrance for 
tubercle bacilli in cases of tuberculosis of the cervical lymphatic 
glands. 

In this connection it is interesting to note that in the tissue of 
the floor of the mouth have been found the staphylococcus aureus, 
streptococcus, diplococcus, and certain bacilli, probably the bacillus 
septicus or the bacillus oedematis maligni of Koch and Pasteur. Prob- 
ably Ludwig's angina arises secondarily from a streptococcic infection 
of the glands, and affected teeth or bones may be an important etio- 
logical factor in both diseases. 



HYPERTROPHY OF THE TONSILS. 205 

Etiology. — Hypertrophied tonsils are found in the very young so 
commonly that they may be spoken of as being congenital, but in 
many instances they develop about the age of puberty. The largest 
number of cases are seen between the ages of 10 and 20 years, the 
next largest under the tenth year, and those occurring between 20 
and 30 years are next in frequency. After the thirtieth or fortieth 
year tonsillar hypertrophy is rather infrequent, for their growth ceases 
and the process of atrophy sets in about the thirty-fifth year. Nearly 
twice as many males are affected as females. 

The rheumatic habit; living in a damp, cold atmosphere; recur- 
ring attacks of inflammation, the throat complications of the eruptive 
diseases, diphtheria, syphilis., and the strumous diathesis are all pro- 
ductive of those conditions that predispose to an increase in the 
volume of these glands, After the thirty-fifth year I do not advise 
the removal of the tonsils unless there is some special reason for it, 
since their gradual diminution in size and tendency to inflame date 
from about this period of life. 

Symptomatology. — The features of a child with enlarged tonsils 
often present a picture which suggests at once the nature of the 
trouble. Previously to an examination of the throat one is often able 
to predict the condition to be found. The under-jaw drops, the 
mouth remains continuously open, the eyelids droop, and the face is 
expressionless and suggestive of a dull intellect (Fig. 71). During 
sleep the respiration is noisy and of a snoring character. Associated 
with hypertrophied tonsils in a large proportion of children so affected 
will be found an enlargement of Luschka ? s tonsil, or adenoid vegeta- 
tions in the vault of the pharynx. In these associated diseases with 
obstruction to the current of air through the nose by adenoids and 
the backward projection of the oral tonsils, and to the passage of air 
through the mouth by the blocking up of the fauces with the oral 
tonsils, the oxygenation of the blood is seriously interfered with. 
The effects on the voice are readily apparent. The resonance of the 
nasal cavities is so diminished that speech has a thick, unnatural nasal 
quality, and the articulation of words is impeded and difficult 
(Plate I). 

The tonsils are situated in such close relationship to the Eusta- 
chian orifices that any disease of these glands threatens impairment 
of the integrity of the Eustachian tubes and middle ears. While the 
tonsils are not so situated as to produce actual pressure upon the 
tube-mouths, as was formerly supposed, any inflammatory action af- 



206 HYPERTROPHY OF THE TONSILS. 

fecting the gland readily extends by continuity to the tubal mem- 
brane. The large number of patients with hypertrophied tonsils who 
suffer from middle-ear diseases is suggestively significant. Mackenzie 
and others speak of defective smell and taste in tonsillar hypertro- 
phies. Great embarrassment of the respiration may interfere seriously 
with the general health, and in very young persons, or those with a 
tendency to rickets, the chest-walls may become deformed, resulting 
in pigeon-breast, or a pyriform deformity. 

Inspection of the throat reveals the tonsils tumefied (Plate III) 
and in some instances so enormously enlarged as to lie in contact with 
each other and to cut off a view of the posterior wall of the pharynx. 
They are generally very red, soft, and yielding, and can be crowded 
through the fenestra of a tonsillotome so small that it would seem 
impossible. 

Diagnosis. — A view of the pharynx under good illumination is 
sufficient to establish the diagnosis. There is a possibility of mis- 
taking an enlarged tonsil for a pharyngeal abscess, but the chances 
are remote. The location of the tonsil and, if necessary, palpation 
with one finger on the tonsil and another over its base under the angle 
of the jaw, would distinguish the location and character of the tumor 
(Plates III and IV). 

Prognosis. — Probably the vast majority of hypertrophied tonsils 
are never removed or even treated, yet it is the exception to find them 
after the thirtieth or fortieth year. This means that there is a natural 
reduction to the normal size after adolescence or middle life. How- 
ever, there are many individuals with impaired hearing that is at- 
tributable either directly or indirectly to the presence of tonsils that 
have been subject to repeated attacks of inflammation. In adult life 
I rarely advise their removal unless they are provocative of some dis- 
turbance, for in many they occasion no inconvenience. But I have 
seen persons in middle life who were subject to so much suffering 
from attacks of quinsy that they sought relief by excision. It must 
not be forgotten that the lacunas of the tonsils, from twelve to eight- 
een in number for each gland, afford nests for the reception and cul- 
ture of micrococci that may give rise to more serious trouble. These 
depressions are sometimes very deep, plunging down into the paren- 
chyma of the gland, and form an ideal incubator for the development 
of micro-organisms. There are warmth, moisture, decomposing secre- 
tions, and a harbor from the currents of air or friction of fluids and 
food thai might otherwise dislodge them.. 



TONSILLOTOMY. 



207 



Treatment. — Iodine internally, astringents to the surface of the 
tonsil, and injections of various drugs into the body of the gland are 
recommended for its reduction, but they are all inane makeshifts that 
worry the patient without benefit to any one but the doctor. The 
tonsil should be removed in its entirety. My aim has always been to 
cut it clean off at the base so as to get below the bottoms of the 
crypts and leave a smooth surface for the stump. 

Tonsillotomy. — Before operating for excision of the tonsil the 
throat should be sprayed with an antiseptic wash, such as dioxide of 
hydrogen or mercuric bichloride, — 1 to 10,000, — to remove or destroy 
any microbes that may be present. We rarely apply cocaine or eu- 




Fig. 78. — The Author's Tonsillotome, with Excised Tonsil. 

caine, for the reason that it is not a very painful operation. The 
gland is not freely supplied with nerves of sensation. But in very 
nervous individuals it may be necessary to employ a weak solution for 
the purpose of a placebo. Occasionally I have been obliged to use the 
bromide of ethyl, removing both tonsils and adenoids during one 
anaesthesia. 

The patient, if a young child, is seated on the lap of an assistant 
or a nurse. One arm of the latter pinions the arms of the child, and 
with the other hand the patient's head is held back against the nurse's 
shoulder by pressure on its forehead. A convenient method is to 
infold the child in a sheet, which is made to fix immovably the arms 



208 TONSILLOTOMY. 

and legs (Fig. 73). Now the tonsillotome (Fig. 78) is introduced 
into the mouth like a tongue-depressor, then turned to one side with 
a movement that causes the ring of the opening to surround the 
tonsil. Sufficient pressure is then exerted to cause it to embrace the 
tonsil at its base. An assistant should press with his thumb or finger 
upon the side of the neck just over the base of the gland so as to pre- 
vent it from receding from the instrument. This counter-pressure 
need not be great, but simply sufficient for support. As the instru- 
ment is pressed into position, the operator's thumb drives the blade 
through the gland until the cutting edge of the guillotine rests 
between the ring-plates. This act completely severs the tonsil and 
secures it between the bevel of the knife and the upper ring-plate. 
Care must always be taken to cut the tonsil clear through before with- 
drawing the instrument. 

Tonsillotomes. — Any physician who has had a considerable ex- 
perience in tonsillotomy with the various tonsillotomes will not be 
likely to deny that these instruments are generally too complicated. 
They are armed with needles, barbs, or sharp-toothed forceps for 
piercing the tonsil and dragging it through the fenestra before any 
cutting is done by the blades. A tonsillotome constructed after the 
pattern I have designed renders the barbs unnecessary. It reduces 
the painfullness of the operation by one-half; it divests the procedure 
of any danger of an accident to the operator or patient; it makes a 
skillful and easy operation possible with a minimum amount of ex- 
perience; it resembles a large, folding tongue-depressor so closely 
that children usually offer no opposition to its introduction for the 
removal of the first tonsil; and it combines strength and compactness 
with simplicity of construction. It is made on the principle of a 
guillotine, the blade of which is propelled by the thumb of the same 
hand that grasps the handle. The latter is set at such an angle to 
the shaft as will permit the most perfect co-ordinate action of the 
muscles of the hand and arm of the operator. I have had two sizes 
manufactured, the smaller having a fenestra of the calibre ordinarilv 
found in such instruments, the other supplied with an aperture larger 
than the largest Mackenzie tonsillotome, while it is so compactly con- 
structed as to require less space in which to operate. I have used 
the larger size to extirpate enormously hypertrophied tonsils in chil- 
dren as young as 2 1 / 2 years, where it was impossible to insert the 
Mackenzie instrument of the necessary size. The smaller one is suffi- 
cient for the majority of eases, but the fenestra is not capacious 



TONSILLOTOMY. 209 

enough to admit the bases of the extraordinary glands we occasion- 
ally see. It is advisable to remove the whole tonsil, and, as the tops 
only of the largest tonsils can be severed with the smaller instruments, 
it may be better to have the larger size, if but one is to be kept. 

The blade is so protected as to make it impossible to wound the 
ascending pharyngeal or the internal carotid artery. The shaft that 
propels the blade is of such a width as to make the use of a gag un- 
necessary, for it protects the finger of the operator from the patient's 
teeth, if it is placed in the mouth to ascertain when the fenestra is 
in such a position as to embrace the whole tonsil, as it is necessary 
for one to do when operating in children with other tonsillotomes. 
Since I have used this guillotine I have not had my finger bitten, 
while it was not an uncommon occurrence, before, to come off sec- 
ond best so far as pain was concerned. With the shank wide enough 
to afford protection, it is unnecessary to introduce the finger into the 
mouth, for the teeth and lips cannot close enough to prevent the 
operator from seeing plainly the field of operation. There is no work- 
ing in the dark or fear of damaging structures one does not wish to 
attack. 

The handle is firmly fixed to the shank with a hinge-joint and 
self-acting spring-lock; so that the fenestra can be pressed down 
about the base of the gland with any degree of power required. This 
feature dispenses with any necessity for hooks, forceps, needles, or 
barbs for spearing the tonsil. The latter, being a soft, fleshy mass, 
adapts itself to the shape of the fenestra and protrudes through it the 
instant its base is pressed around. The pain of spearing or tearing 
the tonsil by toothed or barbed accessories, designed to drag the gland 
through the fenestra before the blade cuts, excites the most vigorous 
struggling and resistance on the part of a child. Even when the 
utmost care has been exercised, the barbs have pierced the soft palate 
or the surgeon's finger, instead of the tonsil. Moreover, the gland 
always comes out with this instrument, the same as though barbs 
were used. There is another important advantage in having the 
handle attached to the shank with a hinge provided with an auto- 
matic lock, for the cutting extremity of the instrument cannot be 
thrown out of your control by a disturbance of the coaptation of its 
parts. The last time I operated with a Mackenzie tonsillotome the 
child jumped just as I was placing the fenestra about the tonsil. 
The shank revolved upon the handle, leaving the latter in my hand, 
while the cutting-end was entirely displaced and removed from the 

14 



210 TONSILLOTOMY. 

vicinity of the gland. It is impossible for this improved tonsillotome 
to play such a trick. The handle contains a concealed spring-lock 
operated by a convenient thumb-plate. When this is moved down- 
ward, the hinge-joint is unlocked and the instrument folds upon itself 
like a pocket-knife, occupying the space of about one and one-fourth 
inches in width and thickness by six and one-half inches in length. 
Another pertinent point, that should not be neglected in this age 
of antisepsis, is the provision for cleansing and disinfecting the three 
pieces of which the instrument consists. By raising the proximate 
end of the horizontal top spring of the shaft and swinging it 90 de- 
grees to either side it becomes disengaged from its lock and liberates 
the blade from the shank. This arrangement makes it as simple as 
possible for taking apart, sterilizing, and putting together again. 

In amputating the apex of a relaxed and elongated uvula the 
blade is inverted. It is claimed by some operators that the remnant 
of the tonsil will become atrophied if its apex only is clipped, but 
I have never been able to find a good reason for half-doing the opera- 
tion. I have never seen any but healthful results from ridding the 
throat of the whole trouble at once. 

There are cases in which one may be in doubt as to whether the 
gland ought to come out or not, because there is but slight hyper- 
trophy, and the appearance of the throat does not seem to warrant 
surgical interference. But those same glands may be honeycombed 
with deep, slit-like crypts that are packed with inspissated, decom- 
posing, irritating, caseous secretions that start the attacks of" sore 
throat that make the patient's life a burden. 

It is a good rule never to part with the patient until one is sure 
that all oozing of blood has ceased. I have seen a few cases of very 
severe haemorrhage, but as a number of such instances are on record 
we must always be alert for them. In the case of a student at the 
Illinois Medical College, a young man of 24 years, I had my first 
experience with profuse haemorrhage from this procedure. After I 
had operated on a number of children during the clinic and had sent 
them to the treatment-room to wait until all signs of bleeding ceased, 
the student requested me to operate on one of his tonsils. On ex- 
amination 1 found ii only slightly hypertrophied, and remarked that 
I did not generally remove glands so little enlarged. However, he 
insisted thai lie had suffered all his life from recurring attacks of 
inflammation, and was anxious to part company with the cause of 
them. Thereupon 1 excised it, but was struck with the very unusual 



TONSILLOTOMY. 211 

amount of resistance offered to the cutting blade. It seemed like 
forcing it through creaking leather. 

As the student left the operating-chair I proceeded with my re- 
marks to the class as follow: "The haemorrhage has entirety ceased 
in all the children and they can now go to their homes. I have re- 
moved a large number of tonsils in the various clinics and in private 
practice without seeing a case of persistent haemorrhage. We have 
never had to resort to measures to stop the bleeding. It generally 
ceases within five or ten minutes spontaneously. But in case of severe 
haemorrhage, what would you do? Excellent remedies are to be had 
in a saturated solution of tannic acid in water; an ice-cold gargle; 
pieces of ice held in the back of the mouth in contact with the bleed- 
ing surface; ice applied to the neck over the tonsil; powdered alum 
rubbed into the tissues; a strong solution of iron persulphate applied 
on cotton or with the finger; 2 drachms of gallic acid with 6 drachms 
of tannic acid to the ounce of water; pressure by forceps both ex- 
ternally and internally upon the tonsil, and firm compression of the 
common carotid artery. This compression reduces the supply of blood 
to the tonsil-stump and encourages faintness, and with fainting the 
haemorrhage will probably cease. 

"There is more bleeding in this young man's case than I have 
e^er seen. It does not diminish. In fact, there is a constant stream 
of blood flowing into the basin. It looks as though we were to have 
our first experience with a persistent tonsillar haemorrhage. I will 
send for ice, and exert firm, deep compression on the common carotid. 
The pallor of countenance and the beads of perspiration show the 
effect of the loss of blood. The profuse haemorrhage is probably due 
to the fact that the recurring attacks of inflammation during the past 
years have left the gland in an indurated, fibrous condition, which 
prevents collapse of the blood-vessels. There is no history of a haem- 
orrhagic diathesis. We will deprive the vessels of their blood-supply 
until coagula form and plug their open mouths, and keep him in a 
sitting posture to assist in this and to promote faintness. We will 
not allow him to gargle fluids for fear of washing away any clots that 
may form, but give pellets of ice instead. 

"It is now forty minutes since the tonsillotom}', and all haemor- 
rhage has ceased. The young man's room-mate will keep watch over 
him and inform us if there should be any return of the trouble, al- 
though I do not anticipate it if he remains perfectly quiet in bed the 
remainder of the day. He complains of feeling faint. 



212 THE LINGUAL, OR FOURTH, TONSIL. 

"This incident illustrates the necessity of always being prepared 
for emergencies. The most successful soldier, lawyer, or doctor is 
the one whom you can never surprise." 

Suprarenal solution, applied on a firm compress to the bleeding 
surface, is effective, but in desperate cases the common carotid artery 
may have to be ligated. 

The young man had no further haemorrhage and made an ex- 
cellent recovery. After these operations patients are given a spray 
of camphor-menthol in lavolin, 3 per cent., for use at home four or 
six times a day until all soreness ceases. 

Edwin Pynchon has devised a method of removing chronically 
diseased tonsils when they are adherent to the faucial pillars and more 
or less buried, or "submerged." He has named this method "electro- 
cautery dissection." It consists in the use of a suitably bent elec- 
trode, of No. 21 irido-platinum wire, heated to a white glow while in 
the open air. Such a heat will give the least pain and the most 
rapid results. The tonsil is lifted toward the median line with a 
toothed, spring forceps while the electrode is entered at different 
marginal points and made to burn outward, gradually dissecting the 
tonsil away from its attachments. In this manner a part or all of one 
tonsil may be removed at a sitting. For adults he removes the upper 
half first, and the remainder in about two weeks. 

In describing the operation he says: — 

"By dividing the operation into two parts there is less soreness 
and less likelihood of secondary haemorrhage. Under cocaine applied 
with a swab, using a 10- or 20-per-cent. solution in combination w T ith 
10 per cent, of phenol, a sufficient anaesthesia is often secured to ren- 
der the operation painless. Haemorrhage at the time of the operation 
is rare, and generally unimportant, though a certain amount of sec- 
ondary haemorrhage occasionally occurs within twelve hours after the 
operation, owing to a paralysis of the muscular coat of the blood-veo- 
sels due to the cocaine." 

The Lingual, or Fourth, Tonsil. 

The lingual, or fourth, tonsil, is situated at the base of the 
tongue, in close relationship with the epiglottis. Histologically it 
closely resembles the other tonsils included in the lymphatic tissue, 
constituting the ring of Waldeyer, which "runs from the tonsilla 
pharyngea to the region of the Eustachian orifice, from there to the 
posterior rim of the velum palati, around the posterior palatal fold 



THE LINGUAL, OR FOURTH, TONSIL. 213 

to the faucial tonsil, over the base of the tongue to the opposite side, 
and by a corresponding direction back to the pharyngeal tonsil" 
(Kayser). 

The lingual tonsil is subject to the same pathological changes 
which occur in the faucial and pharyngeal tonsils, and, undoubtedly, 
many throat symptoms, such as globus hystericus, are attributable to 
this gland when the cause is not recognized. It may give rise to 
fugitive pains in the throat, cough, sense of fullness or of a foreign 
body, fatigue and impairment of the voice, and difficult swallowing 
and breathing. Occasionally there is some haemorrhage due to the 
rupture of varicose veins in its vicinity. 

Treatment. — The writer has obtained the most satisfactory re- 
sults from electrocauterization of the gland, when it was diseased or 
so large as to cause distressing symptoms, using a large electrode at 
a white glow. Robert Levy's experience is the same (Denver Medical 
Times, October, 1900). J. Price-Brown cauterizes a number of the 
larger nodules at a time under cocaine anaesthesia, operating at inter- 
vals of several days. C. G-. Coakley cauterizes from six to ten times at 
intervals of a week or ten days. 



CHAPTER XVII. 
DISEASES OF THE PHARYNX (Continued). 

Mycosis of the Pharynx. 

Synonym. — Pharyngomycosis. 

Pathology. — This is a very rare parasitic disease of the superior 
pharyngeal space, including the tonsils. Small, white or yellow 
growths appear, projecting above the mucous membrane, instead of 
occupying a recessive position, as is the case with tonsillar concre- 
tions. They may invade the lacuna?, but are not confined to them. 
They spread upon the soft palate, the pharyngeal membrane, and base 
of the tongue. As I have seen it, the growth is not soft like the 
cholesteatoma of the tonsil, but tough and somewhat difficult to re- 
move in its entirety. It has, in some instances, a fungoid appearance, 
and penetrates the mucosa to such a depth as to prevent its removal 
with a probe. 

Etiology. — The cause of this disease is obscure, but the micro- 
scope reveals the leptothrix buccalis, which finds a habitat in carious 
teeth. 

Symptomatology. — Xo conspicuous symptoms are produced by 
this disease, but patients discover the growths accidentally and apply 
to have them removed. 

Diagnosis. — The diagnosis is easily made, since the symptoms 
of inflammation characterizing pharyngitis, tonsillitis, etc., are want- 
ing. It is distinguished from tonsillar concretions by the prominence 
of the growths and their location without the lacuna 1 . 

Prognosis. — The tendency is not toward a spontaneous cure. 
The disease is very pertinacious and, like the regeneration of the 
drumhead, these growths often reproduce themselves as fast as they 
are removed. 

Treatment. — If caries of the teeth is found it must receive at- 
tention. Delavan uses the curette and follows this with the galvano- 
cautery. After removing the fungi the membrane should be sprayed 
with undiluted hydrozone or mercuric bichloride, 1 to 10,000. Each 
growth should be treated as has already been recommended for en- 
(314) 



CONCRETIONS IX THE TONSIL. 215 

larged pharyngeal follicles, using cocaine and then cauterizing half 
a dozen points at one sitting. In a monograph on pharyngomycosis 
leptothricia benigna, published in the New Yorker medizinisclie Presse, 
December, 1886, Max Toeplitz reviews the literature of the subject. 
Carbolic acid, sesquichloride of iron, and the sublimate solution, 1 
to 2000, are recommended. Toeplitz uses the galvanocautery and 
curette. Homer M. Thomas also reports success from the galvano- 
cautery. 

Concretions in the Tonsil. 

Pathology. — The tonsillar crypts are sometimes filled with an 
accumulation of dried secretions that consist principally of carbonate 
and phosphate of lime in the hard variety, and of a cholesteatomatous 
mass in the soft deposits. The latter consist of cholesterin, epithelial 
cells, pus-corpuscles, and micro-organisms. The hard concretions are 
called chalky or cretaceous concretions or calculi, and the soft ones 
cheesy or caseous deposits. These conditions are comparable to cer- 
tain diseases of the ear that have been considered: cretaceous deposits 
in the drumhead and cholesteatoma of the tympanic and mastoid 
cavities. 

Etiology. — Tonsillar deposits are due to an inflammation of the 
walls of the lacunas. 

Symptomatology. — The symptoms are not of a troublesome na- 
ture. A sensation of irritation or fullness, especially when swallow- 
ing, may be the only unusual thing to be noticed. The deposit can 
generally be seen as a cheese-like point, and several will likely be 
found by a careful examination. Sometimes they will be overlooked 
unless hunted for with a blunt-pointed probe to depress and bring for- 
ward the mouth of each opening. The difference in the consistence 
of the masses is readily detected by the sensation imparted through 
the probe. Patients often observe these concretions in their sputa, 
with which they have been expelled in the form of little, yellowish 
balls. Their presence is a menace to the health of the gland, for they 
degenerate into irritating excitants of inflammatory processes. 

Treatment. — With the tongue depressed these concretions are 
removed without difficulty by the curette (Fig. 191). If they are re- 
produced the crypts should be treated to the hot electrode or some 
other cautery. H. W. Whitaker uses a 50-per-cent. solution of tri- 
chloracetic acid on a cotton-carrier for destroying the secreting sur- 
faces of the tonsillar crypts (The Laryngoscope, November, 1897). 



216 



UVULITIS. 



UVULITIS. 

Inflammation of the uvula is sometimes more intense than the 
inflammatory action affecting the remainder of the pharynx. The 
swelling, oedema, and elongation of the uvula then constitute the 
conspicuous features of the disease. It increases to several times its 
normal proportions and hangs pendent upon the tongue, down toward 
the larynx. In this condition it gives rise to frequent swallowing and 
coughing (Plate III, No. 8). 




Fig. 79. — Bifid Uvula in a Man Sixtv Years Old. (Author's Case.) 



Treatment. — For the purpose of reducing the swollen, oedema tous 
condition of the uvula a saturated solution of suprarenal extract is in- 
dicated. It should be plentifully applied repeatedly at intervals of 
three minutes until its effects arc observed. Occasional reapplicationa 
may be necessary until the inflammation subsides. If the uvula is 
much elongated (Plate 111) it should be clipped^ with care that not 
enough be amputated to leave it too much abbreviated when swelling 



BIFID AND DOUBLE UVULAS. 217 

recedes and contraction takes place. I have known it to be com- 
pletely removed by mistake, probably on account of the operator's 
poor sight, and the articulation of words was perceptibly defective. 
On the other hand, I have known syphilis to destroy it without pro- 
ducing this effect. 

Bifid and Double Uvulas. 

Considerable interest has been manifested of late in the subject 
of cleft uvulas, and a number of articles in the medical journals have 
given it much prominence. Some of the writers have maintained 
that these abnormalities are exceedingly rare, and that they call for 
prompt surgical interference to effect the removal of the super- 
numerary members. 

These anomalies are certainly not common, but the examinations 
of a very large number of throats in Chicago have given the author 
the opportunity of seeing quite a large number of such cases. In 
nearly all instances the uvula is bifid somewhat as shown in Fig: 79, 
a photograph of a man 60 years old. We very rarely find two com- 
plete uvulas, as seen in the boy, 14 years old, in Fig. 80. More 
than 50 per cent, of the cases that have come under my observation 
show a division not to exceed one-half of the entire length of the 
uvula, and many of these show a bifurcation extending not more than 
one-third of its entire length. The upper portion of the uvula was 
often normal until about its lower one-fourth was reached. This 
branched out into two extremities with a mere notch of greater or less 
depth between them. 

In some instances the two portions of the uvula were of unequal 
length, one being sufficiently elongated to lie upon the dorsum of 
the tongue. Speech was not perceptibly impaired, and no difficulty in 
deglutition was found. A. H. Ohmann-Dumesnil (The Laryngoscope, 
October, 1897) claims that "the entire absence of the uvula is of 
much more frequent occurrence than a double one." The author's 
experience is the reverse of this. Congenital absence of the uvula has 
been rarely seen by him, although its absence through pathological 
causes is not very infrequent. 

The author has taken pains to question this class of patients 
relative to any inconveniences which they may have experienced from 
the conditions of their uvulas. With only a few exceptions they were 
entirely unconscious of the existence of any such anomaly. A few 



218 



BIFID AND DOUBLE UVULAS. 



of the most intelligent and observing ones had discovered it and re- 
garded the cleft as a mere curiosity. 

Bifid and double uvulas are anomalous, rather than diseased, 
conditions. They are undoubtedly closely associated with those cir- 
cumstances which cause cleft palate, and, as Trelat believes, they 
are, to an extent, hereditary. In Fig. 80 the process approaches very 
nearly to that which eventuates in cleft palate. 




Fig. 80. — Complete Double Uvula in a Boy of Fourteen Years. 

(Author's Case.) 



Treatment. — The author cannot agree with those writers who 
advocate trimming or amputating these supernumerary uvulas. in the 
absence of any definite indications for surgical procedures. The 
owners of these extra appendages were generally innocenl of a sus- 
picion that there was au unusual condition of their throats. If the 



TUBERCULOSIS OF THE PHARYNX. 219 

elongated branch or branches tickle the tongue and cause cough- 
ing, the same reasons exist that we have in the same conditions of 
single uyulas for clipping the relaxed or elongated ends; but there 
is no occasion for the operation for cosmetic purposes. Here, as 
elsewhere, the knife should not be resorted to "without just cause or 
provocation." 

Tuberculosis of the Pharynx. 

Tubercular invasion of the throat is of infrequent occurrence. 

Pathology. — A granular condition of the mucous membrane of 
the pharynx, showing areas of a gray color, precedes the breaking 
down of the epithelial layer that ushers in the stage of ulceration. 
The ulcers are superficial, of irregular forms, and ill defined. Like 
a granulating wound, they respond to the touch by bleeding. 

Pharyngeal tuberculosis is generally secondary to miliary in- 
vasion of the lungs, and rarely develops in children. The granular 
neoplasm usually precedes the stage of ulceration. The writer has 
not met with the primary form, although he has seen the ulcerative 
form associated with laryngeal and pulmonary tuberculosis repeatedly. 
The nodules soon degenerate and break down into ragged ulcers, 
which may be surrounded by oedematous tissues. A yellowish secre- 
tion, sometimes thick, tenacious, and stringy, covers the eroded 
surface, and the frequent and distressing attempts to dislodge and 
expectorate this tenacious discharge are the cause of much suffering 
and exhaustion. 

Etiology. — The throat invasion is generally secondary to the 
same affection of other organs. 

Symptomatology. — The cough, constantly elevated temperature 
and accelerated pulse, loss of appetite and the characteristic expres- 
sion of countenance, pallor of skin, and the habit of the body point 
toward the invasion, of the great white plague. If the lungs are in- 
volved there will be expectoration, with cough; if not, the cough 
may be, at first, dry and hacking. The most conspicuous and distress- 
ing symptom is pain, especially during movements, of the muscles con- 
cerned in deglutition and speech. The proper nourishment of the 
patient is interfered with by the difficulty and pain experienced in 
swallowing. He will refrain as long as possible from taking food, in 
order to escape the torture of eating. Inspection reveals the granular, 
or ragged, ulcerated condition of the mucous membrane already de- 
scribed. 



220 



TUBERCULOSIS OF THE PHARYNX. 



Diagnosis. — Tubercular throat must be distinguished from syph- 
ilitic ulceration. The history of syphilis and the family history of 
tuberculosis must be sought. The latter disease is usually one of 
adult life, while syphilis, especially the congenital form, may occur 
in children. Syphilis is not attended by fever, and generally not 
by pain or very difficult swallowing. Its ulcers are clearly defined, 
with red areola and clean-cut borders possibly undermined. The 
ulcers of tuberculosis are shallow, ragged, and pale. They differ from 
scrofulous ulcers in that the latter are deep, with well-marked bor- 
ders, and pain, fever, and cough are generally absent, while the mus- 
cles of phonation and deglutition cause-little or no pain by their move- 
ments. The scrofulous affection occurs principally in children in 
whom there are no evidences of tuberculosis. 

The following points in the differential diagnosis between tuber- 
culous and syphilitic ulcers are given by Lennox Browne: — 



TUBEECULOUS ULCERS. 

No apparent excavation. 
Much indolent granulation. 

Faint areola. 

Irregular and ill-defined edges. 

Demarkation indistinct. 

Grayish, ropy, mucous secretion. 

Discharge scanty. 

Superficial, with lateral, instead of 

deep, extension. 
Fever. 



Syphilitic Ulcers. 
Deeply excavated. 
Few granulations, and those highly 

inflammatory. 
Deep-red areola. 
Sharply cut edges. 
Demarkation distinct. 
Yellow, purulent secretion. 
Discharge copious. 
Penetrating to deep tissues. 

No fever. 



Prognosis. — This is an acute affection that proves quickly fatal 
from exhaustion. The average duration of the disease varies from six 
weeks to six months, but it may be prolonged much beyond the latter 
time. 

Treatment. — For the relief of the most prominent symptom, pain, 
Sajous strongly recommends the application of a 10-per-cent. solu- 
tion of cocaine, after cleansing the ulcers with a borax solution of 1 
per cent, in the form of a spray ("Diseases of the Nose and Throat/' 
1892). He deprecates cauterization with silver as more hurtful than 
beneficial. Steam-inhalations of hot infusions of opium, belladonna, 
hyoscyamus, and conium produce a soothing, sedative effect and ren- 
der swallowing less painful. A solution of creasote and menthol in 
lavolin, in the proportion of 2 per cent, of creasote to 10 per cent, of 
menthol, makes an excellent topical remedy. Iodoform insufflations 



TUBERCULOSIS OF THE PHARYNX. 221 

have proven beneficial, but aristol is preferable. It is devoid of a 
disgusting odor and taste, is slightly anaesthetic, and adheres to the 
surfaces of the ulcers better than any other powder. Before apply- 
ing any of these local remedies the discharges covering the ulcer- 
ated surfaces must be washed off by hydrozone or such an alkaline 
spray as DobelFs or Seiler^s. A solution of sodium bicarbonate, 3 
grains to the ounce, is also useful for this purpose. The cauteriza- 
tion of tuberculous ulcers by lactic acid, as practiced by Krause, is 
probably productive of more benefit than any other method. The 
ulcers are treated similarly to lupus. After cleansing and cocainizing 
them the acid is rubbed in by means of a cotton pledget, using a 
solution of 20- to 40-per-cent. strength, to begin with, and increasing 
the strength rapidly to 80 and 100 per cent. As fast as the eschars 
become detached, which they do in a few days, the treatments are 
repeated, until the process of cicatrization is seen to begin. If the 
tubercular granulations are covered with mucous membrane the latter 
must be incised to give the acid access to the lesions beneath. Heryng 
uses sharp curettes to scrape away projecting masses of tumefied 
tissues. 

Cicatrization sometimes follows this method, but close watch 
must be kept for renewed breaking out of the disease in either the 
cicatrices or at new points. 

J. Solis-Cohen condemns galvanocauterization as injurious "ex- 
cept under the most skillful manipulation." 

Ingals makes use of either morphine troches or the following 
spray: — 

fy Morphiae sulphatis, gr. iv. 

Acidi tannici, 

Acidi carbolici, . . . . .of each, gr. xxx. 

Glycerini, 

Aquae dest., of each, f^ss. 

Tuberculin and tuberculocidin have not fulfilled the expectations 
of the profession. The former has proven positively harmful, and 
since patients do as well under other forms of treatment as with the 
use of the latter, their employment is not recommended. 

Creasote has been largely used internally and applied locally in 
recent years, and, while undoubted benefit has accrued from its use 
in the hands of eminent practitioners, there are some who discourage 
its employment. However, in a disease so intractable, and discour- 
aging to both patient and physician as this must be admitted to be, 



222 TUBERCULOSIS OF THE PHARYNX. 

whatever has proven beyond cavil and reasonable doubt to have been 
helpful in treatment is worthy of trial. Great caution is necessary 
in its administration to patients who have high temperature or haem- 
orrhages. It is given in doses of 1 to 10 minims or more three times 
a day, preferably in milk, as recommended by Glasgow. It can be 
given at any time with reference to meals, but is best taken before 
meals if well borne, since it then exercises a preservative influence 
upon ingested food against the process of decomposition. The effect 
of this upon the promotion of nutrition is apparent. 

Creasote is readily taken in the form of capsules, or it may be 
combined with alcoholic or tonic preparations, as used by Cohen. 

The feeding of this class of patients is an important subject. 
When the high temperature does not forbid much animal food, as 
much should be consumed as is consistent with good digestion. Milk, 
cream, codliver-oil, eggs, and vinous stimulants support the strength. 
improve nutrition, and prolong life. Added to these, the vegetable 
bitter tonics, iron, and quinine act as valuable aids to enrich the blood 
and increase the general tone of the body. 

An out-door life in a high, dry, sunshiny, warm climate, with 
equable temperature, is conducive to the improvement of these pa- 
tients, especially when combined with proper protection of the body 
by woolen underwear and a healthful employment of the mind and 
body in a cheerful or useful occupation. The most favorable climates 
are those of Southern California, Arizona, and Xew Mexico. Eobert 
Levy says of Colorado: "I cannot add that our Colorado climate, so 
beneficial to pulmonary and, at times, to laryngeal phthisis, lias any 
remedial influence upon pharyngeal tuberculosis. Miliary tubercu- 
losis, with which tubercular ulceration of the pharynx is often asso- 
ciated, presents no encouragement in any climate, but in our high 
altitude it is my conviction that cases so afflicted decline very rapidly. 
The climate can only be of value in such cases as present no evidences 
of miliary tuberculosis or advanced disease, either local or constitu- 
tional/' (Denver Medical Times, June, 1896.) 

Syphilis of the Pharynx. 

Although the throat is subject to the manifestations of syphilis 
in the three stages of that disease", the primary lesion is not often 
observed in this locality. The history ol' chancre in the pharynx 
i- similar to that of the same ulcer in other localities, with a duration 
of about si.\ weeks. The secondary Lesions are of frequent occurrence 



SYPHILIS OF THE PHARYNX. 



223 



and the characteristic mucous patches are readily recognized. The 
tertiary stage is represented by the presence of gummata or eroding 
ulcers. The congenital form generally shows itself about five or six 
weeks after birth by the appearance of secondary lesions, and the 
tertiary stage at any time preceding the fifteenth or sixteenth year. 

Pathology. — Chancres are generally found on one tonsil, while 
the secondary and tertiary lesions show a special predilection for the 




Fig. 81. — Large Perforation of the Velum Palati. (Author's Case.) 

The lower border is covered with a light-colored discharge. 

Perforation closed entirely in three months. 

soft palate. The syphilitic eruptions of the throat are similar to those 
occurring in other parts of the economy and are often coincident with 
them. In the early stage papular elevations make their appearance, 
the epithelial covering of which becomes eroded; or erythematous 
patches occur in the form of a blush or mere hyperemia of transi- 
tory duration; or the epithelium of these areas becomes exfoliated, 
leaving a denuded, pus-secreting mucous membrane beneath. These 



224 SYPHILIS OF THE PHARYNX. 

mucous patches now assume an ashy-gray color, with a rough, granu- 
lar surface. They are eruptions of the secondary period of syphilis 
and extend their boundaries so as to invade a large territory in a 
comparatively brief period. They are surrounded by a red areola and 
a well-defined border, and there is a copious, purulent, nasty discharge 
from them. 

In the tertiary stage the ulcers are deeper than the mucous 
patches of the secondary period. The infiltration extends to the 
whole depth of the membrane and results in irregular thickening and 
induration in the form of nodules or gummata. If these are incised 
in the early stage they exude a glairy fluid. In time they degenerate 
into a caseous mass, which becomes surrounded by dense connective 
tissue. They are closely analogous to tubercle, but differ from the lat- 
ter in their greater tendency to the formation of connective tissue. The 
increased proliferation of connective tissue produces pressure on the 
blood-vessels that supply the gummata with nutrition, thus cutting 
off their own nutrient sources. Breaking down and softening follow 
in each gumma, presenting a yellow spot which is soon the seat of an 
ulcer. 

The mucous patches of the secondary stage are superficial and 
may end in resolution with contraction of the tissues as the cicatrix 
forms. The tertiary ulcers may occur in any part of the pharynx. 
They extend rapidly and deeply, perforating the pillars of the fauces 
or the velum (Fig. 81) in a few days, and gradually eating away the 
whole velum, uvula, and faucial columns, as illustrated by one of my 
cases in Fig. 82. 

Etiology. — The specific virus of syphilis is yet one of the un- 
known quantities in medicine, notwithstanding the fact that a con- 
siderable percentage of humanity are, or have been for many genera- 
tions, infected by it. The occurrence of the primary lesion in the 
mouth or pharynx is generally in consequence of kissing or of using 
utensils not thoroughly cleansed after having been used by syphilities. 
They may also result from certain practices of sexual perverts. The 
secondary stage of syphilis is quite generally accompanied by throat 
lesions, and next to the genitals the throat is the most frequently 
affected. Tertiary manifestations may crop out in the pharynx a 
quarter of a century after the appearance of the initial sore, but the 
average interval is about seven years ("the perfect number' 7 ?). 

Symptomatology. — The primary lesions- of the throat are at- 
tended with so slight a disturbance that they are altogether likely to- 



SYPHILIS OF THE PHARYNX. 



225 



be overlooked. Trie submaxillary lymphatic glands may be enlarged 
and tender to the touch. Inspection discloses a red, or perhaps a 
gray, denuded spot with prominent edges. It generally disappears 
spontaneously. As already remarked, the initial lesions are found 
principally on the tonsil. 




Fig. 82. — Destruction of the Velum Palati. 



Fournier "recognized syphilitic ulcer of the tonsil in 40 per cent, 
of his cases of ulcers of the mouth. The sore is generally single, and 
sometimes covers the whole tonsil, occasionally extending to the 
pillars of the fauces and to the base of the tongue. The erosive form 
is the most common. The symptoms are trifling, but the ulcerative 
form causes pain and difficult swallowing; the ulcers are brown, gray, 



15 



226 SYPHILIS OF THE PHARYNX. 

or yellow and the tonsil is indurated." Occasionally there is some 
systemic disturbance. 

Secondary symptoms manifest themselves as an erythema or as 
mucous patches on one or both sides of the throat. The erythematous 
eruption occurs either in blotches, suggestive of the roseola, or it may 
appear as a diffused redness spreading over the whole pharynx. This 
stage is attended with the usual symptoms of simple sore throat. 
After a few days distinct patches are clearly made out on the anterior 
columns or on the velum and other parts of the throat or mouth. 
The sides of the tongue near its base are especially liable to surfer. At 
first these mucous patches appear as slight, rounded elevations of a 
dark-red color. Their centres soften and break down, leaving a 
characteristic, slightly cup-shaped excavation, which later assumes a 
gray color. In this stage swallowing is attended with pain. 

The tertiary lesions generally begin by attacking one tonsil and 
the adjacent faucial pillars. The nodular and gummatous points 
begin to show signs of breaking down, then the epithelial layer cover- 
ing them grows thin, revealing a yellow spot underneath. Finally 
the epithelium is exfoliated, exposing an ulcerating process which 
penetrates the mucosa deeph", leaving an accentuated cup-shaped de- 
pression surrounded by uneven, but prominent, ragged edges. These 
ulcers are rapidly destructive to the soft tissues, and do not seem to 
be retarded in their erosive action by cartilage or bone. I have seen 
them perforate the soft palate in a few days, and for a time no treat- 
ment would stay their progress or appear to produce any impression 
whatever. The whole soft palate is sometimes destroyed, as I have 
seen in a series of cases (Fig. 82). Cicatricial contractions have the 
effect of narrowing the lumen of the throat, and adhesions may en- 
croach seriously upon the upper part of the pharynx or even shut it 
off from the lower part by adhesions of the soft palate to the posterior 
pharyngeal wall, similarly to the condition shown in Fig. 8-i. 

It is somewhat remarkable to observe the trivial character of 
the subjective symptoms as compared with the extensive gnawing 
away of the structures of the throat. I have seen this corrosive proc- 
ess plowing through the faucial columns and the velum, leaving per- 
forations, eating away their borders until several small apertures 
united into one large hole, destroying one of the supporting shreds 
of the velum, and allowing the ragged remnant to drop and hang as 
a pendant, swaying and fluttering with the currents of the air. Pa- 
tients subject to these erosions sometimes appear to experience 



SYPHILIS OF THE PHARYNX. 



927 



inconvenience from them than others suffer from a common cold. 
But in some individuals much pain attends, the process, and swallow- 
ing causes a distressing effort. Solids must be eschewed and the diet 
confined to liquids until amelioration of the condition can be brought 
about. 

Diagnosis. — This disease may be mistaken for tuberculosis, and 
in the early stage may be confounded with a simple catarrhal inflam- 
mation of the mucous membrane. But the latter yields readily to 
treatment, while the syphilitic disease progresses uninfluenced by any 
other than specific treatment. 

In tuberculosis serious constitutional disturbances are present, 
such as are not accompaniments of syphilis: fever, emaciation, etc. 
The areas of hyperemia that later become the seat of ulceration are 
paler and softer in tuberculosis than in syphilis. The ulcers of syphi- 




Fig. 83. — The Author's Small Powder-blower with Long Tube. It can 
be operated by a small rubber bulb, also. 



lis have more regular, clearly defined borders and are deeper than in 
tuberculosis. The pain of the latter disease, especially in swallowing, 
causes great suffering, while it may not be a prominent symptom of 
syphilis and may be absent altogether. The patient improves and 
gains in weight on specific treatment in syphilis, but grows worse in 
tuberculosis. The presence of pulmonary tubercular lesions will aid 
in clearing up the diagnosis. 

Prognosis. — The primary sore disappears in about six weeks. 
The secondary lesion is about that time in coining on after infection 
and lasts approximately the same length of time when left to nature. 
The third stage is far more serious, for, while the primary and sec- 
ondary periods may not menace health or life, the tertiary form in- 
vades all tissues with a wanton destruction that is sometimes ap- 
palling. Important structures are not immune. A large blood-vessel 
may be opened and cause a fatal haemorrhage. Contractions of cica- 



228 SYPHILIS OF THE PHARYNX. 

tricial tissues may constrict the throat and seriously interfere with 
breathing, swallowing, and speaking. 

Treatment. — Cleansing solutions should be used on the ulcerating 
surfaces before local applications will be of any avail. For this pur- 
pose I have had satisfactory results from hydrozone and the alkaline 
antiseptic solutions of Dobell and Seiler, in the form of a coarse spray 
with sufficient force to the stream to dislodge and wash away all the 
dirty secretions. These are good, cleansing, soothing sprays for the 
primary lesions and the erythema also. Then we touch the denuded 
surface with tincture of iodine, pure, by means of a small cotton 
pledget twisted hard upon the silver applicator. When the iodized 
cotton is pressed upon the ulcerating part, not enough of the tincture 
should be left to run down over the healthy membrane. This treat- 
ment is usually followed by a drying up of the discharges and the 
institution of a healthy granulating process. 

If the throat is exceedingly painful, especially upon swallowing, 
one is justified in painting it with a 4-per-cent. solution of cocaine 
just before meals, to insure sufficient ingestion of food to support the 
strength. After cleansing and drying the ulcers with absorbent cot- 
ton, we cover them with a coating of aristol or nosophen by means of 
a small powder-blower (Fig. 83). The antiseptic and slightly anaes- 
thetic effects of aristol, besides its power of promoting granulation 
formation, have seemed to me to transcend the properties of any other 
single remedy. Sajous cleanses with a solution of potassium perman- 
ganate, and uses zinc sulphate or lead acetate, in a 5-grain solution, 
for their astringent effect, or 5 minims of the tincture of the chloride 
of iron in a drachm of glycerin. Mackenzie used 20 grains of the zinc 
chloride to the ounce for the erythema, and tincture of iodine for the 
mucous patches. If the ulcers were indolent he preferred copper sul- 
phate, 15 grains to the ounce. In the secondary and tertiary periods 
I employ mercury and potassium iodide, the mixed treatment, and 
tonics, with whatever general treatment the condition of each patient 
suggests. 



CHAPTER XVIII. 
DISEASES OF THE PHARYNX (Continued). 

Anomalies and New Growths. 

Anomalies of the pharynx are most conveniently treated of 
under two headings: (1) malformations and deformities and (2) new 
growths. 

MALFORMATIONS AND DEFORMITIES. 

Malformations of the pharynx are of two varieties: stenoses and 
dilatations. Stenoses either exist from birth or they may be acquired, 
in which cases they are called congenital, on the one hand, or post- 
natal, on the other, and they may be either complete or incomplete. 
The congenital form is due to some intra-uterine anomaly of develop- 
ment. While the stenosis may be located in the upper part of the 
pharynx, where the nasal and oral portions meet, it is more frequently 
met with in the lower division, opposite the cricoid cartilage of the 
larynx. Then, at this point is found a diaphragm of mucous mem- 
brane, which constricts the passageway to one-half or less of its nor- 
mal lumen, and complete atresia has been known. 

The high stenosis, which occurs in the palatal region, is caused 
by a membranous expansion extending backward and laterally from 
the soft palate to the back wall and sides of the pharynx. 

The acquired, or post-natal, malformations are due to two kinds 
of causes: intrinsic and extrinsic. As examples of the former, which 
originate within the pharynx, the following may be mentioned: Diph- 
theria, scarlet fever, small-pox, erysipelas, lupus, syphilis, and trau- 
matisms. Examples of the latter, or causes originating and operating 
without the pharynx, are tumors, abscesses, and deformities of the 
spine. 

Intrinsic stenoses are quite likely to be attributable to syphilis, 
when the appearance of scar-tissue in the diaphragm and in the 
neighboring soft parts, and particularly the presence of a perfora- 
tion of the hard palate, will clear up the diagnosis. Scarlet fever is 
occasionally responsible for a pharyngeal stenosis. 

(229) 



230 MALFORMATIONS AND DEFORMITIES OF THE PHARYNX. 

These constrictions of the pharynx may not give rise to actual 
pain, or even serious inconvenience, unless they become the seat of 




Fig. 84.— Stenosis (if the Pharynx. (The Author's Case.) The re- 
sulting diaphragm is perforated behind the uvula. 

an inflammation, which is noi a common occurrence. In one of my 

cases, shown in Fig. 84, a young lady's throat is divided into superior 



MALFORMATIONS AXD DEFORMITIES OF THE PHARY.NX. 231 

and inferior portions by an. adventitious membrane extending between 
the posterior columns and arch of the palate, on the one hand, and 
the lateral and posterior pharyngeal Avails, on the other. An oval 
aperture is seen behind the uvula, through which nasal respiration 
takes place. The only inconvenience suffered is the lodgment of 
particles of food behind the new membrane. This aponeurosis, or 
pharyngeal diaphragm, is the result of the throat affection attending 
scarlatina, which she had when she was a small child. 

Among the traumatic causes of stenosis of the pharynx we may 
mention scalding liquids and chemical caustics, such as carbolic acid, 
lye, etc. 

Treatment. — If the adhesions are of a syphilitic character, gen- 
eral treatment should be instituted, combining the mercurials and 
potassium iodide. The local treatment, which has principally pre- 
vailed, consisted in the employment of graduated bougies for the pur- 
pose of dilating the strictures; but this method promises indifferent 
results, since the fibrous tissues are prone to contract again after the 
dilatations cease. 

The electric cautery presents a more effective remedy. The 
membrane should first be treated to a strong solution of the supra- 
renal gland. Then an 8-per-cent. solution of cocaine is repeatedly 
applied, not by means of a spray, but by cotton firmly twisted on a 
holder. This is carried to all parts of the periphery of. the dia- 
phragm. The object of reversing the customary order of applying 
these remedies is as follows: We contract the blood-vessels and 
minimize the amount of cocaine that may be absorbed and which 
might produce toxic effects. When the tissues are previously con- 
tracted, the cocaine penetrates them relatively more deeply, and for 
that reason renders the operation the less painful. The writer always 
employs the remedies in this order, and has found it possible by this 
method to use the stronger solutions without toxic effects. ISTo more 
cocaine should be applied than will moisten the area to be operated 
upon. So extensive an absorbing surface must be treated to cocaine 
in throat surgery that one should be on his guard to avoid the use of 
too great an amount of the drug. Most deplorable accidents have 
been brought to the writer's knowledge, but these were undoubtedly 
due to the use of too strong preparations or to spraying the parts. 
Instead of employing 20- or 33-per-cent. solutions, it is wiser to con- 
fine one's self to the 4- or 8-per-cent. preparation for the sake of 
safety. 



232 DILATATION OF THE PHARYNX. 

The operation consists of entering the periphery of the mem- 
brane with an electrode and passing this around the circumference 
until the adventitious tissue is completely detached. The electrode 
should be hot enough to show a white glow when not in contact with 
the tissues. As it burns its way through, the heat closes the mouths 
of the blood-vessels — sears them over — so as to prevent haemorrhage, 
providing that the electrode is removed from contact with the tissues 
while it is still hot. After the operation the patient should be kept 
under observation a sufficient length of time to satisfy the surgeon 
that there is no danger from haemorrhage. Should any occur, the 
suprarenal solution must be used to stop it, after which a cotton 
pledget saturated with a 10-per-cent. solution of silver nitrate should 
be pressed firmly against the bleeding surface, or the solid pencil of 
the same may be employed. If the stenosis has been occasioned by 
lupus, the x-ray treatment should be employed. 

Extrinsic stenosis of the pharynx is due to such causes as tumors 
and abscesses. For example, there may be a goitre, an aneurism, a 
deformity of the spinal column, or a retropharyngeal abscess. 

Dilatation. 

When the pharynx becomes dilated, the wdiole or only a part of 
the tube may be affected. This condition usually presents a pouch, 
or sac, which becomes more and more distended with advancing years. 
The congenital form is due to a prenatal anomaly of development. 

The post-natal dilatation, or diverticulum, results from a de- 
fective or weakened state of the muscular Avails of the pharynx, which 
readily yield to pressure exerted by large boluses of hastily swal- 
lowed food. The unhealthful habit of bolting imperfectly masticated 
food is a cause only secondary to an inherent weakness of the phar- 
yngeal tunic. When a weakened area once yields to pressure the 
dilatation may continue, very much as an aneurism of an artery grad- 
ually distends, until the pouch becomes several inches long. It gen- 
erally projects downward and posteriorly to the oesophagus, lying 
alongside the cervical spine. It is usually covered by the submucous 
and mucous pharyngeal tissues, but it may also be enveloped m the 
cellular membrane of the oesophagus. Sometimes a tumor is found 
in the side of the neck, formed by a deflection of a pharyngeal pouch 
toward that side. 

The most constant symptom of this anomaly is caused by the ob- 
struction which it oilers to the act of swallowing. Food lodges and 



DILATATION OF THE PHARYNX. 233 

accumulates in the sac until its distension interferes with degluti- 
tion. But the afflicted one usually learns to manipulate the pouch 
and press out its contents. Otherwise the contained food is liable to 
undergo decomposition and set up an inflammatory process, with dis- 
astrous consequences. However, it has happened that such an in- 
flammation eventuated in the formation of adhesions between the 
opposing walls of the sac, with the result of closing it and curing the 
anomaly; but the danger lies in a probable sloughing of the adjacent 
structures. Distressing symptoms may be occasioned by the ejection 
of the imprisoned food from the sac into the larynx. Suffocative at- 
tacks, spasmodic coughing, bronchitis, and even pneumonia may 
supervene. 

Diagnosis.; — The diagnosis is rendered a simple task if, in addi- 
tion to bearing in mind the symptoms already detailed, we observe 
that the tumor can be dissipated by pressing out its contents of undi- 
gested food, that it recurs again on the ingestion of food, that the 
ejection of undigested matters is not coincident with an act of vom- 
iting, and that particles gain entrance to the larynx at other times 
than during a meal. In addition to these points the use of the throat- 
mirror and a digital exploration will afford corroborative evidence. 

Prognosis. — The prognosis is not favorable in the absence of cor- 
rective operative interference. There is an abiding danger of putre- 
factive changes in the retained food, and resulting inflammation, sup- 
puration, and sloughing. To obviate such consequences, it may be 
necessary to restrict the patient's diet to fluids. In favorable cases 
the anomalies may be obliterated by operative intervention. 

Treatment. — Before passing to the subject of operative treat- 
ment we will consider what the patient may do to promote his com- 
fort and safety. While partaking of food he should exert pressure 
over the pouch in such a manner as to prevent food from entering it, 
or he can wear a compress over it to accomplish the same purpose. 
Whenever food enters the sac he should manipulate it until it is 
evacuated, and he may even wash it out with a properly constructed 
syringe, so as to prevent the fermentation and putrefaction of food. 

Operative treatment consists first in applying the electric cau- 
tery to the periphery of the mouth of the diverticulum so that ad- 
hesions between these freshened opposing surfaces will result in their 
permanent union and a consequent obliteration of the entrance to 
the cavity. This is done after the exhibition of the suprarenal solu- 
tion and cocaine, as we have previously described in the treatment 



234 NEW GROWTHS OF THE PHARYNX. 

of stenoses of the pharynx. After this operation rectal alimentation 
should be resorted to until the adhesions are sufficiently firm. Cer- 
tain cases may not lend themselves to this kind of an operation, when 
such measures as are employed in pharyngotomy and cesophagotomy 
may need to be brought into requisition, after which the edges of the 
divided membrane should be sutured in order to perfect the closure of 
the tube. 

NEW GROWTHS OF THE PHARYNX. 

The following classification will be adhered to in treating of 
pharyngeal neoplasms: — 

f Papilloma. 
1. Epiblastic and hypoblastic -l Cystoma. 



Carcinoma. 
f Fibroma. 



2. Mesoblastic ^ l ^° 

Angioma 

Sarcoma. 



Papilloma. 

Papilloma is an epithelial tumor having a benign character, and 
is made up of epithelial cells and a framework of connective tissue 
beneath the epithelial proliferation. The vascular area is within 
this tissue and separated from it by the membrana propria. This 
form of tumor is liable to degenerate into a malignant one, especially 
so when it is situated, as it is in this case, in a passageway which sub- 
jects it to frequently repeated irritation. For this reason it becomes 
the seat of recurring attacks of inflammation, and further predisposes 
the patient to an extension of this inflammation to adjacent struc- 
tures: to the larynx and even to the lungs. Papillomata are fre- 
quently found on the velum palati, the uvula, the faucial pillars, the 
tonsils, and on the posterior wall of the pharynx, and they vary in size 
from a hemp-seed to an ordinary cherry. 

Symptomatology. — The symptoms produced by papillomata. be- 
fore they become subject to an inflammation or to degenerative 
changes into malignant tumors, may be of no moment. Indeed, 
many patients are ignorant of the existence of those neoplasms in 
their throats until informed of their presence by their physicians. 

Diagnosis. — The diagnosis is attended with little or no difficulty, 
especially when they are not inflamed. They resemble small warts, 
and may have a cauliflower appearance. They are either red, pale- 



NEW GROWTHS OF THE PHARYNX. 235 

pink, or of a gray color, and their surfaces, moistened with secretions, 
reflect the light from their convex peripheries. If any doubt exist as to 
their nature, a section should be taken in each case from the base of 
the growth for a microscopical examination. 

Prognosis. — The prognosis in most cases may be said to be favor- 
able. We have encountered many instances in which no appreciable 
s3 T mptoms were referable to these growths. On the other hand, there 
is the ever-present liability of their undergoing a transformation into 
carcinomata or sarcomata. 

Treatment. — For the sake of reducing to a minimum the likeli- 
hood of inflammatory attacks and a degeneration of the tumors, papil- 
lomata had. best be extirpated and the seats of attachment should 
be well cauterized. The growths may be severed and their seats of at- 
tachment cauterized at the same time by the employment of the elec- 
tric snare or knife. Or the tumor may be cut off with the scissors, cold 
snare, or a knife, and the attachment treated by a chemical caustic, 
such as silver nitrate. 

Cystoma. 

In cystoma the wall of the cyst is produced from a matrix of em- 
bryonic cells, and the products of tissue-proliferation of the cells lin- 
ing the cyst-wall constitute the contents of the sac. These are not 
frequently met with in the pharynx, but retention cysts are formed 
in consequence of inflammatory processes in the ducts leading from 
glands. The resulting stenoses of these ducts obstruct the progress 
of the secretions from the glands outward. Hence, an accumulation 
of the secretion takes place, distending the ducts more and more 
behind the constrictions until the swellings appear. The pressure of 
the contents of the sacs on their epithelial lining causes atrophy of 
the latter, which becomes greatly attenuated. These cysts are gen- 
erally found in adults and those who are past middle age. 

Treatment. — The cysts should be opened and evacuated, and 
their walls should be destroyed. The electric cautery, or the knife 
and the curette, may be employed. After the latter, the pencil of 
silver nitrate should be used. 

Carcinoma of the Pharynx. 

Pathology. — Cancer of the superior portion of the pharynx is 
generally of the scirrhous form, and presents, in its early history, an 
indurated mass not clearly defined in its circumference. At first the 



236 NEW GROWTHS OF THE PHARYNX. 

mucous membrane covering it may not show any visible changes. 
The growth may extend to include the soft palate and pharyngeal 
vault. As the epithelium breaks down and ulceration of the surface 
of the tumor begins, a fetid exudate bathes the surface, which assumes 
a red or light-greenish appearance. Large, pedunculated granulations 
are sometimes to be seen, during this carious process, springing from 
the floor of the ulcer. The submaxillary lymphatic glands become 
infiltrated early in the attack. 

When the cancer is situated in the lower part of the pharynx, 
or the pharyngo-laryngeal cavity, it generally takes on the character 
of epithelioma. Its most usual site is a little below the arytenoid 
cartilage. Instead of the red or light-greenish surface of ulcerating 
scirrhus, this variety presents a gray surface inclosed by the very red, 
tumefied, mucous membrane. The disease spreads until it circum- 
scribes the passage. 

Etiology. — "Recent researches have been made with a view of 
demonstrating the microbic origin of the primary and secondary 
tumors, but so far no conclusive proof has been furnished of the mi- 
crobic origin of carcinoma. Our present knowledge concerning the 
origin and growth of carcinoma warrants us in making the statement 
that carcinoma is the result of an atypical proliferation of epithelial 
cells from a matrix of embryonic cells of congenital or post-natal 
origin, and the local and general infections are caused b)' the local and 
general dissemination of carcinoma-cells." (N. Semi.) 

Symptomatology. — Inspection reveals the presence of a tumor 
or an ulcerating surface. The symptoms are characteristic of a lesion 
obstructive to respiration and deglutition. Phonation is interfered 
with, the speech is thick, and there is a foul-smelling, frothy ex- 
pectoration. Swallowing is painful, but the suffering is not limited 
to this act, being constant and sometimes extending to the Eusta- 
chian tubes and ears. 

Diagnosis. — This is not obscure. It is possible to mistake this 
for a syphilitic lesion, but the use of mercury and potassium iodide 
will remove all doubt. In a case recently under my observation the 
attending physician was not able to reach a conclusion. 1 suggested 
that a mixed treatment would soon result in recovery, which in a 
few weeks followed, demonstrating the specific nature of the lesion. 

Prognosis. — Sooner or later death closes the scene. 

Treatment. — Hitherto, palliative measures "have formed the chief 
reliance of the plrysician. If death is impending by obstruction to 



NEW GROWTHS OF THE PHARYNX. 237 

respiration, intubation or tracheotomy may prolong life. Nourish- 
ment may be administered by the oesophageal tube or by enemata, 
when swallowing is obstructed. Cocaine, morphine, and sedative 
sprays afford temporary relief only. 

Thomas Hubbard reports a case of squamous epithelioma of the 
velum palati cured by injections of caustic potash by a curved plati- 
num needle. Injections were repeated wherever proliferating epi- 
thelial growths were seen. Cicatrization w T as rapid as well as the 
general improvement. The case remained cured after two years. 

Karl Schwalbe, 0. Hasse, and others have advocated injections 
of alcohol into cancerous growths as a curative measure, and instances 
have been reported in which complete cures have been claimed as the 
result of these interstitial injections. As having a direct bearing on 
this subject, we will refer to the following observations of Hasse, 
which cover a broad field: "Alcohol favors cicatrization in all growths 
like struma, angioma, cysts, lymphatic-gland tumors, sarcoma, carci- 
noma, and especially carcinoma of the breast and cervix uteri. Under 
its use, in fifteen out of eighteen cases of carcinoma of the breast, the 
growth gradually dwindled away until in a year there was nothing 
left but the connective-tissue stroma, and there has been no return. 
Five cases of carcinoma of the cervix also recovered completely, and 
the patients are still living and in good health. The effect on the 
general health is even more surprising. The pains and uneasi- 
ness pass away, and sleep, appetite, assimilation, and strength re- 
turn in a most remarkable manner." This method of treatment has 
been applied to cancer of the naso-pharynx with promising results, 
and should be given extensive trials to definitely determine its lim- 
itations of usefulness in this field. 

Schwalbe and Hasse reasoned that if alcohol would produce con- 
traction and atrophy of tissues, as occur in the cirrhotic liver of the 
inebriate, it would have a similar effect on a neoplasm into the paren- 
ch}nna of which it might be injected. While the former believes that 
its curative effect is produced, when injected into the interior of the 
tumor, by causing the formation of new connective tissue, with the 
obliteration of blood-vessels, lymphatics, and the parenchyma, Hasse 
practices injection into the circumference, maintaining that the new 
connective-tissue formation, girdling the periphery of the growth, 
would choke the afferent and efferent blood-vessels and thus cause 
atrophy. 

Hasse employs a Windier syringe, but others prefer a Pravaz. 



238 NEW GROWTHS OF THE PHARYNX. 

The alcohol is used in the strength of from 30 to 50 per cent. At first 
but a small quantity may be endured, for the injections are very pain- 
ful, but the quantity may be increased gradually from 6 to 30 or 40 
minims. 

The object of the interstitial injections is to surround the tumor 
with alcohol so as to cause contraction of the connective tissue, fatty 
degeneration of the cancer-cells, and obliteration of the blood-vessels. 

FlBEOMA. 

See "Fibrous Tumors of the Naso-pharynx," page 131. 

Lipoma. 

A lipoma may be either a circumscribed or a diffuse tumor, and 
consists of fatty tissue produced from a matrix of lipoblasts. It is 
not often found in the pharynx, but, when present, it gives rise to 
the well-known symptoms of a foreign body in the throat.' It is likely 
to be mistaken for an abscess when it has a soft consistency, but the 
absence of symptoms pointing toward pus-formation, and an explor- 
atory puncture or incision, will clear up the doubt. 

Treatment. — When the tumor is pedunculated it may be removed 
by the electric snare or knife or the cold-wire snare, but, if it is of the 
diffuse type, resort should be had to electrolysis. 

Angioma. 

Yirchow included in this class all vascular tumors, but the re- 
stricted definition of the present day limits the application of this 
term to a growth consisting of new blood-vessels which communicate 
with the surrounding vessels, of interstitial tissue the same as that 
from which the tumor springs, and of the blood within the vascular 
spaces. On the other hand, growths that are composed of lymphatic 
vessels are designated as lymphangiomata. 

Cruveilhier's submucous venous plexus, which is an oval group 
of veins in the back portion of the pharynx, may become so engorged 
and tumefied as to produce symptoms comparable to those which are 
occasioned by a foreign body in the pharynx and an irritating cough. 
The surface presents a purple, dense, and tabulated appearance. It 
is not uncommon to find groups of varicose veins in the pharynx that 
resemble clusters of currants, or blackberries, which bleed on being 
irritated. These tumefactions may give rise to much discomfort and 
anxiety, and they interfere with the articulation of speech, and with 



NEW GROWTHS OF THE PHARYNX. 239 

swallowing, when they reach considerable proportions. They also 
provoke efforts to swallow, and may even embarrass respiration and 
cause serious haemorrhages. 

Treatment. — "When angiomata give rise to the distressing symp- 
toms mentioned, they should be extirpated; but, as they are generally 
sessile, or diffuse, instead of pedunculated, electrolysis is best adapted 
for their eradication. If the tumor is of considerable proportions and 
profuse haemorrhage is imminent, it may be necessary to perform 
thyrotomy after a preliminary tracheotomy. 

Sarcoma. 

This is an atypical proliferation of connective-tissue cells from a 
matrix of fibroblasts of congenital or post-natal origin. It springs 
from the submucous connective tissue, and generally depends from 
the inferior surface of the body of the sphenoid bone into the phar- 
ynx. Owing to the rich supply of lymphatic structure in this locality 
and its invasion by the sarcomatous cells, the tumor may show a 
transition into the variety which is known as lymphosarcoma. For- 
tunately, this growth is not frequently met with in the pharynx. 

Symptomatology. — The symptoms produced by a pharyngeal sar- 
coma relate to impairment of the voice and embarrassment of swal- 
lowing and breathing. There is an increase in the secretions of the 
naso-pharynx, and, after ulceration occurs, the discharge is tenacious, 
bloody, and foul; but serious haemorrhages are not necessarily a part 
of the history of sarcoma. When there is pain, it is proportioned to 
the degree of pressure on the surrounding parts. 

Diagnosis. — The diagnosis should be rendered certain by a resort 
"to microscopical examinations of sections from the tumor. 

Prognosis. — The prognosis is an unhappy one; the progress is 
toward a fatal termination. 

Treatment. — If the growth can be enucleated from a circum- 
scribing pseudocapsule, leaving no remnant of diseased tissue, and no 
metastasis has occurred to render nugatory the result of the opera- 
tion, it should be done. It is useless to operate if a part of the growth 
be left, for a rapid reproduction will occur; and, if metastatic tumors 
have formed in other parts, nothing will avail from operative pro- 
cedures. Then there is little to be done save rendering the conditions 
as tolerable as possible by the employment of detergent, disinfecting, 
and astringent applications. 



CHAPTER XIX. 
DISEASES OF THE PHARYNX (Concluded). 

Retropharyngeal Abscess. 

Etiology. — Abscess in the posterior pharyngeal wall may result 
from acute inflammation of the pharynx or of the submucous tissue 
and glands; from a middle-ear suppuration, in consequence of the 
pus breaking through the anterior wall of the tympanic cavity or 
through the semicanal for the tensor tympani muscle, and from a 
disease of the vertebra?. It is more likely to occur in the strumous 
or syphilitic, and may be a sequel of the eruptive fevers or diphtheria. 
Traumatism resulting from the swallowing of fish-bones, the impact 
of a lead-pencil, etc., or scalding liquids and destructive chemicals- 
may give rise to retropharyngeal abscess. 

Symptomatology. — If the abscess is located in the upper and 
back part of the pharynx there is a sensation of fullness accompanied 
by obstruction to nasal respiration with nasal voice. The tumor may 
be seen in this locality with the rhinoscopic mirror, and if it is not too 
high it may become visible by using the palate-elevator (Plate IV). 
On passing the finger into the vault of the pharynx it meets with a 
resistance which may be mistaken for adenoid vegetations. When 
it is posterior to the base of the tongue it can be brought into view 
by the use of the tongue-depressor. If the swelling is behind the 
glottis and attains a large size it is liable to press on the epiglottis 
and embarrass its functions. The swallowing of foods and liquids is- 
so interfered with as to cause their entrance into the larynx. Dysp- 
noea of such a serious degree as to endanger the patient's life may 
result from an abscess in this region. Occasionally the tumefaction 
increases to such a size as to be visible by means of a swelling in the 
side of the neck. The inflammatory process may extend to the cer- 
vical glands, producing induration, pain, and tenderness. 

The head generally assumes a position suggestive of torticollis, 
being held fixedly to one side with the face upl limed and everted. 

The general condition is one indicative of a severe illness. The 
temperature is often somewhat elevated, and thirst adds to the gen- 
(240) 



RETROPHARYNGEAL ABSCESS. 241 

eral discomfort. Like tonsillar abscess, rupture takes place usually 
into the throat. The evacuation of pus may fill the larynx and cause 
strangulation, or, if relief is not obtained early enough by incision or 
rupture, a dangerous or fatal oedema of the larynx may occur, or the 
pus may burrow among the cervical muscles and produce an abscess 
of the neck, or it gravitates to the thoracic cavity. 

Inspection shows a bulging of the mucous membrane at the seat 
of the swelling. The tumefaction and the contiguous structures 
present a dark, dusky-red hue, including the uvula and soft palate. 
Fluctuation can be felt by pressure with the finger over the bulging 
surface. 

Diagnosis. — Eetropharyngeal abscess may be confounded with 
other inflammatory affections of the throat, but the absence of cough, 
pseudomembrane, vocal changes, and ulcerative conditions of the 
mucous membrane, taken together with the presence of obstruction 
to respiration and deglutition, the unnatural fixation of the cervical 
muscles and twisting of the neck, the presence of bulging and fluctua- 
tion in the walls of the pharynx proper are decisive diagnostic fea- 
tures. 

Treatment. — If seen early, ice (Fig. 194) should be applied to 
discourage pus formation. As soon as fluctuation can be made out 
the abscess should be punctured with bistoury or trochar, making an 
opening sufficient to evacuate the cavity, but not large enough to 
cause a profuse gush of the contents so as to overwhelm the patient 
by filling the larynx and causing strangulation. MacCoy recommends 
that the incision be made high enough in the swelling to necessitate 
pressure on the tumor to empty it, so as to avoid too great and con- 
tinual flow of pus. The incision should be made in a nearly vertical 
direction, leaving a small wound, so as not to favor the entrance of 
food into it during the act of swallowing. The internal carotid artery 
must be avoided by cutting toward the median line. Cocaine or 
eucaine should be painted, in a 4-per-cent. solution, over the part 
to be entered, before the operation. A trochar can be used instead 
of the knife, but care is necessary to prevent it from plunging be- 
yond the abscess, as the wall yields, and injuring the parts beneath. 
The vertebrae are easily damaged by such an accident. The instant 
the abscess is opened the patient's head should be thrown forward 
to prevent the flowing of pus and blood into the larynx. The part 
of the knife-blade that is not to enter the tissues is protected by 
twisting cotton firmly around it as is done on the cotton-carriers. 

16 



242 NEUROSES OF THE PHARYNX. 

The blood is likely to be found impoverished, demanding iron 
and a nutritious diet. Alteratives containing iodine and the bitter 
tonics are useful. The throat should receive proper attention until 
the wound heals, and any abnormality present should be corrected. 

Neuroses of the Pharynx. 

There are two varieties of neuroses affecting the pharynx, — one 
of sensation, the other of motion. 

NEUROSES OF SENSATION. 

These affections are of four kinds: hyperesthesia, anaesthesia, 
paresthesia, and neuralgia. 

Hyperesthesia. 

The upper portion of the pharynx is liable to increased sensitive- 
ness in persons subject to frequently recurring attacks of inflamma- 
tion, and in the hysterical. No other abnormality may be discernible 
in the individual aside from the exquisitely sensitive throat. 

Treatment. — If any inflammatory condition appear on examina- 
tion, this must be combated by such remedies as have been mentioned 
for pharyngitis, etc. If the condition give considerable discomfort 
one may be justified in applying cocaine or eucaine in a 4-per-cent. 
solution, without the patient's knowledge of the nature of the rem- 
edy. A 10-per-cent. solution of carbolic acid in glycerin obtunds the 
sensibilities of the nerve-ends, and does not present any of the objec- 
tions applicable to cocaine. The membrane can be protected by an 
emollient and slightly anesthetic spray consisting of camphor-men- 
thol in lavolin. It is best to begin with a 3-per-cent. solution of this, 
giving the patient directions to use it in an atomizer for home treat- 
ment, and increase to a 10-per-cent. solution in office treatment, 
which can readily be done if the stronger preparation is employed in 
the vaporizer or nebulizer (Figs 13 and 14), at first, and afterward in 
a coarser spray (Fig. 12). 

Aristol is preferable to most other powders, for its local anaes- 
thetic and adherent qualities. Aconite in glycerin, a salol- or anti- 
pyrin- spray, or guaiacol applications diluted with glycerin at first, 
pure afterward, are indicated if a rheumatic or gouty condition exist. 
Added to these, sodium salicylate, salicin, antipyrin, and lithium are 
effective in ridding the system of the uricacideima that may lie at the 
root of the trouble. 



NEUROSES OF THE PHARYNX. 243 

If the case is of an hysterical nature, sedatives and tonics are 
required: valerian, the bromides, strychnia, arsenic, iron, etc. 

Anaesthesia. 
Loss of sensation is of less import than its exaltation, since it is 
not accompanied with like suffering. It is sometimes a sequel of 
diphtheria or insanity. Nerve-tonics, such as are mentioned above, 
and galvanization are indicated. 

Paresthesia. 

Patients sometimes experience the sensation as if some foreign 
body were in the throat, when it is impossible to make out either the 
presence of such foreign body or any evidence that it may have at any 
time found lodgment. Indeed, no abnormal condition whatever of 
the pharynx is discernible. This condition obtains in hysterical indi- 
viduals, and it is difficult to satisfy them that they are mistaken. 
This manifestation is purely of a neurotic character and must be 
treated accordingly. 

Treatment. — Such methods as are recommended for hyperes- 
thesia are appropriate here, — nerve -stimulants, tonics, or sedatives, 
as the particular features of the case may demand. 

Neuralgia. 

"While painful sensations in the pharynx are sometimes attrib- 
utable to inflamed follicles, uric-acid irritation and various local le- 
sions, there is a class of cases in which pain is experienced without the 
presence of any visible morbid process to account for it. This occurs 
in hysteria and is very difficult to influence. 

Treatment. — If any local lesion can be discovered it must be 
treated according to the principles already laid down, but when the 
pain is purely neurotic, topical applications to the sensitive or painful 
spot, if it can be located, and nervines, sedatives, and tonics, as set 
forth in treating of hyperesthesia, must be brought into requisition. 

NEUROSES OF MOTION. 

Two kinds of neuroses of motion are met with: spasms and 
paralysis. 

Spasms. 

Spasmodic contractions of the pharyngeal muscles may be ex- 
cited by any local irritant: traumatic, such as harsh particles of food; 



244 NEUROSES OF THE pharynx. 

or idiopathic, such as inflamed follicles; or the affection may be 
purely neurotic, such, for example, as globus hystericus. The levator 
palati muscle is occasionally subject to choreic attacks, in which the 
soft palate is thrown against the wall of the pharynx with more or 
less regular contractions and relaxations, accompanied by objective 
smacking or crackling sounds. These spasms may be associated with 
serious and grave neuroses, as well as with inflammatory conditions of 
the soft palate. Central nervous lesions and hydrophobia are char- 
acterized by this symptom. 

Treatment. — If pharyngeal spasm can be traced to inflammation 
of the velum or oedema of the uvula, the proper treatment already 
outlined for these conditions will afford relief. Anomalous condi- 
tions of the nasal cavity must be searched for, and inflamed follicles 
in the pharynx that might provoke the attacks. Any local diseased 
condition must be corrected. When the contractions are dependent 
upon other maladies the treatment must naturally be addressed to the 
initial affection, such as brain-tumors and hydrophobia, for the spasms 
constitute a symptom only of such diseases. Diffusive nerve-stimu- 
lants, tonics, and hygienic and dietetic measures appropriate to each 
case will be suggested by the conditions present. 

Paralysis of the Pharynx. 

Paralysis of the muscles of the pharynx results from diphtheria, 
syphilis, some central nervous lesion, or the fatal fevers. All the 
pharyngeal constrictor muscles may be involved or the disease may 
affect only one, or the muscles of one side alone are sometimes in- 
volved. There may be paralysis of one-half and paresis only of the 
opposite half of the pharynx. 

Swallowing and speech are more or less impaired, according to 
the extent of the paralysis. Food, and especially liquids, regurgitate 
into the posterior nares or enter the larynx. The latter accident is 
the more likely to occur when the epiglottis is included in the par- 
alytic condition. 

Treatment. — The therapeutic measures will be determined by 
the nature of the lesion on which the paralysis depends. If it is 
a sequel of diphtheria, strychnia and arsenic are indicated. Ex- 
cellent results have been reported from the subcutaneous injections 
of strychnine. In addition to tonics we prefer for such conditions a 
current from the primary coil of a faradic battery, which, as the gal- 
vanometer demonstrates, possesses galvanic properties. This will 



FOREIGN BODIES IN" THE PHARYNX. 245 

cause contractions of the muscles if the disease has its origin in the 
nervous centres, but in case of atrophy of the muscles they do not 
respond to the current. The condition in the latter case is unpromis- 
ing. In addition to electrical treatment three or four times a week, 
general tonic remedies are usually called for. 

Burns and Scalds of the Pharynx. 

The pharynx is the seat of injury from inhaling very hot steam, 
air, or smoke, especially in burning buildings. Firemen are particu- 
larly subject to these accidents. Children sometimes inhale steam 
from a tea-pot or tea-kettle or pour hot liquids down their throats. 
Patients and nurses by mistake give escharotic fluids instead of the 
correct internal medicine. I have had patients whose throats were 
severely burned by aqua ammonia and carbolic acid in strong solu- 
tions that were administered by mistake from bottles standing beside 
those containing the proper remedies. 

Symptomatology. — Immediately after these accidents the mu- 
cous membrane of the throat is of a gray color, produced by the 
destructive agent. Inflammation follows, with more or less sup- 
puration and sloughing of the tissues. 

Diagnosis. — This is usually made by the patient or his friends 
before the arrival of the physician. 

Prognosis.— Firemen and persons caught in burning buildings 
are often so seriously burned by inhaling heat, hot smoke, and steam 
that recovery is impossible. There may be such an extensive break- 
ing down of the tissues in the throat as to have a stenosis if recovery 
take place. 

Treatment. — Icebags (Fig. 194), cool drinks, or pellets of pure 
ice in the mouth afford some relief and tend to modify the severity 
of the inflammation. Nourishment may have to be given for a time 
per rectum. When the larynx is involved to the extent of impending 
suffocation, tracheotomy must be performed at once. 

Foreign Bodies in the Pharynx. 

It is not uncommon to find fish-bones, pins, needles, and bristles, 
among sharp-pointed articles, lodged in the walls of the pharynx. 
As the constrictor muscles contract about them, they are forced into 
the soft tissues, until in some instances they escape detection on first 
looking into the throat. I have found such bodies as sections of 



246 FOREIGN BODIES IN THE PHARYNX. 

juniper-leaves, etc., so imbedded as to be extracted with the greatest 
difficulty. This is especially true when they have remained for a 
number of days in the throat, exciting continued efforts at swallowing 
and setting up an intense congestion and swelling of all the sur- 
rounding structures. 

Besides articles of a sharp, piercing nature that penetrate the 
tissues, bodies like unmasticated boluses of food and coins occasion- 
ally slip into the gullet and threaten strangulation. 

Symptomatology. — Sharp bodies are generally arrested in their 
progress by being caught in the lateral walls of the pharynx, where 
they will be found projecting from the tissues which they have pene- 
trated. Small bodies are likely to lodge on one side of the epiglottis 
in the pyriform sinus. The large boluses of food, coins, etc., are 
arrested at a point just posterior to the larynx or a little superior to 
it, and are very liable to catch upon the epiglottis and force it down- 




Fig. 85. — Mackenzie's Lateral Throat Forceps. 

ward. Little bodies often drop into the pyriform sinus or the glosso- 
epiglottic fossa. 

The symptoms produced by foreign bodies in the throat are 
sometimes very distressing and even dangerous. If the epiglottis is 
forced downward so as to close the entrance to the larynx the patient 
may suffocate before relief arrives. When sharp articles stick in the 
throat they produce a pricking sensation, which increases during the 
act of swallowing. Pebbles, buttons, and the like may remain secreted 
in the pyriform sinuses for a considerable time without giving rise to 
serious inconvenience. 

It often happens that when crusts of bread and other hard sub- 
stances are swallowed they scratch the mucous membrane of the 
throat, and this abrasion, giving rise to irritation, produces the im- 
pression in the mind of the patient that a foreign body is present. I 
have known them to insist strenuously upon the presence of some 



FOREIGN BODIES IN THE PHARYNX. 247 

substance; but an application of a 4-per-cent. solution of cocaine to 
the irritated area removed it apparently. There is also a similar sen- 
sation due to a point of irritation which may be found to exist in an 
inflamed follicle. 

Certain susceptible persons occasionally believe they are afflicted 
with a foreign substance in the throat when the trouble is purely a 
nervous one, — globus hystericus. 

Treatment. — Sometimes foreign bodies can be seen by depressing 
the tongue, but generally the laryngeal mirror is necessary. Eemem- 
bering what has been said about the points of lodgment of the various 
kinds of bodies, and ascertaining, if possible, from the patient what 
the object was most likely to have been, the search is much facilitated. 
Sometimes it is best to insert the ringer to locate the body, and it may 
be possible to extract it during this examination. 

Long, curved forceps are best adapted to this use (Fig. 85). One 
should be careful to not wound the adjacent tissues in the effort to 
grasp the foreign body. 

In extreme cases it may become necessary to open the trachea 
in order that respiration may proceed until the body can be rescued. 
A bolus of food may be forced down into the oesophagus if it cannot 
be extracted. Considerable irritation or inflammation follows these 
accidents. 



PART III. 



Diseases of the Larynx, 



(249) 



PLATE \ 



ANATOMY OF THE LAKYNX. 

Figs. 1 to 9. 



a, Thyroid cartilage. 

b, Cricoid cartilage. 

c, Arytenoid cartilage. 

d, Cartilage of Santoriui. 

e, Cricothyroid membrane. 
J, Vocal band. 

g, Arytenoideus muscle. 

h, Lateral cricoarytenoid muscle. 

i, Posterior cricoarytenoid muscle. 

j, Epiglottis. 

k, Vocal process. 



m, Cartilage of Wrisberg. 

71, Aryteno-epiglottic fold. 

o 1 , Upper fasciculus of thyro-arytenoid muscle. 

o", Middle fasciculus of thyro-arytenoid muscle. 

o 3 , Lower fasciculus of thyro-arytenoid muscle. 

p, Ventricle of the larynx. 

g, Laryngeal sac. 

/•, Ventricular band. 

v, Superior aryteno-epiglottic muscle. 

t, I", Two fasciculi of thyrocricoid muscle. 

u, Superior thyro-arytenoid ligament. 



ABDUCTION AND ADDUCTION. 



Fig. 1. 

posterior view. 

Vocal bands abducted by 
contraction of posterior crico- 
arytenoids (arytenoideus cut 
off). 

Fig. 4. 



Fig. 2. 

lateral view. 

Section of larynx showing 
the relation of adductor and 
abductor muscles. 



Fig. 3. 
posterior view. 
Vocal bands adducted par- 
tially by contraction of lateral 
cricoarytenoids (arytenoideus 
not having acted). 

Fig. 5. 



HORIZONTAL SECTION OF LARYNGEAL FRAMEWORK. ABOVE VOCAL BANDS. 

Vocal bands in abduction. Vocal bands in partial adduction. 



EXTENSION AND RELAXATION. 



Fig. 6. 
lateral section. 



Kelaxation of vocal band 
through contraction of thyro- 
arytenoids and relaxation of 
thyrocricoids. 



Fig. 7. 

lateral section, 

Interior of larynx. Flaps 

raised to show laryngeal sac, 

and the relation of muscles 

with the mucous membrane. 

Fig. 9. 
anterior section. 
Interior of larynx and rela- 
tion of muscles. 



Fig. 8. 

lateral section. 

Extension of vocal band by 
elevation of the cricoid carti- 
lage through contraction of 
the thyrocricoid muscles and 
relaxation of the thyroaryt- 
enoids. 



Fig. 10. 

innervation of the larynx. 

Posterior section of neck and upper part of chest, showing 
the course of the pneumogastric nerves, their branches, and 
their relations. Lateral half of trachea and quarter of larynx 
cut off. 



A 1 , Pneumogastric nerve. 

£ l , Superior laryngeal. 

Pught recurrent laryngeal. 

Plight lung. 

Lett recurrent laryngeal. 

Branch of superior laryn- 
geal. 

(Esophagus. 

Aorta. 

Pulmonary artery. 

Trachea. 

(upper;, Internal jugular 
vein cut off. 

(lower), Bronchi. 

Arytenoid cartilage. 

Subclavian artery. 

< oiuinon carotid artery. 

External carotid artery. 

Internal carotid artery. 

Base <>f cranium. 

(upper), First cervical ver- 
tebra, 

(lower), Arytenoideus 
muscle. 

Pharynx cut oil from upper 
attachments. 

Epiglottis. 

II void bone. 

I h\ mill cartilage. 

Cricoid cartilage. 



s, Thyroid gland. 
u, Thyrocricoid muscle. 
v, Cervical vertebra;. 
x, y, Muscles of neck. 
z, Innominate artery. 



Fig. 11. 

arteries and veins of the 
anterior portion of the 

NECK. 

Vessels of the neck, show- 
ing those in danger of being 
severed in making artificial 
opening into the larynx and 
trachea, and their connec- 
tions. 

a, Trachea, 

h, Cricoid cartilage, 
c, Thyroid cartilage. 

Thyroid gland. 

Cricothyroid membrane. 

Thyrohyoid membrane. 

11 void bone. 

Aorta. 
/,' Innominate artery. 
/', Common carotid artery. 
/-, Superior thyroid artery. 
/, Anterior jugular vein. 
///, < ricothyroid artery. 
«, Internal jugular vein. 
o, Thyroid plexus. 
p, Bight interior jugular vein. 
7. I.ci'i Inferior jugular vein. 
/•. Cricothyroid vein. 

.v, Superior thyroid vein. 
', Middle thyroid vein. 

External Jugular vein, 
c, Subclavian vein. 
jr, Bight and left innominate 

\ cm 
>/, Superior vena cava. 



PLATE II, 




CHAPTER XX. 
DISEASES OF THE LARYNX. 

Indirect Laryngoscopy and Instruments. 

Examination of the interior of the larynx, commonly called 
laryngoscopy, is made by means of a light reflected into the larynx 
through the medium of two mirrors. The first, or forehead-, mirror 
is illustrated in Fig. 110, and is used in the same manner as in otos- 
copy and rhinoscopy, described elsewhere. The second mirror, some- 
times dignified by the name of laryngoscope, consists of a circular 
plane-glass mirror inclosed in a metallic frame, to which is attached a 
wire handle set at an angle of 120 degrees to the plane of the mirror 
(Fig. 5). It is made in several sizes, but those most commonly em- 
ployed vary from one inch (twenty-five millimetres) to one-half inch 
(twelve millimetres) in diameter. The most perfect view is obtained 
by using as large a mirror as the proportions of the throat will permit 
without contact between mirror and mucous membrane. The sizes 
are numbered according to their diameters, No. 1 being t one inch 
(twenty-five millimetres) wide, and the others graded by one-eighth- 
inch (three millimetres) variations down to one-half inch (twelve 
millimetres), and numbered accordingly. In the capacious throats 
of adults the largest size is to be used, while in children the smaller 
ones are necessary. 

For the purposes of illumination there are various devices for 
projecting the rays of light upon the laryngeal mirror. Fig. 86 shows 
an ingenious device of Allen De Yilbiss, which is a modification of 
Mackenzie's light-concentrater. It is simpler in construction than 
Tobold' s apparatus, although it is similar to it. It is provided with 
two mirrors, one plane and the other concave, both of which are at- 
tached to a stationary mirror-bar by means of ball-and-socket joints, 
so arranged that they may be easily changed to any position on the 
bar and inclined at any angle. 

The plane mirror enables the physician to show his patient the 
condition of the affected parts, and, if needing treatment, illustrate 
its necessity. "By this method patients may see the extent and 

(251) 



252 



INDIRECT LARYNGOSCOPY. 



nature of their diseases and receive treatment when they might other- 
wise consider it of but little importance, not demanding medical as- 
sistance." If deemed advisable, the patient may be shown, from time 
to time, the changing condition of his disease, and thus be kept in- 
terested in its treatment. By this device the patient can see to keep 
himself "in light," thus relieving the physician from the necessity 
of frequently adjusting the mirror. This laryngoscope can be ad- 
justed to a student's lamp, and may be raised or lowered by means 



of a single set-screw. 



Fig. Ill shows another adjustable lamp. 




Fiff. 8G. — De Vilbiss Illuminator. 



Assuming that we have proper illumination, the examination 
proceeds as follows: The patient and examiner being in the relative 
positions illustrated in Fig. 86, with the patient's mouth open, the 
tip of his tongue is taken between the physician's thumb and index 
finger, protected from actual contact with the tongue by a napkin or 
thin towel, and the tongue is held protruded from the mouth. The 
patient should not make an effort to force the tongue forward nor 
to retract it, but should let it lie passively in the surgeon's control. 
This is necessary in order to raise the epiglottis and expose the aper- 
ture of the larynx. This is effected by traction on the glosso-epiglottic 



INDIRECT LARYNGOSCOPY. 253 

ligament, which happens in the drawing forward of the tongue. Un- 
less the examiner is careful in this act he will wound the fraenum on 
the sharp edges of the lower incisor teeth. It is advantageous to 
instruct the patient to assist in his examination by holding his tongue 
himself, using the hand opposite to the one used by the examiner, so 
as not to be in the way of the laryngeal mirror as it is introduced. 

The light is now focused on the uvula, and the front of the 
laryngeal mirror is exposed for only an instant over a flame to warm 
it. This must be done in order to prevent the moisture of the breath 
from condensing upon the glass and blurring the laryngeal image. 
After a second of warming the mirror it is touched to the surgeon's 
cheek, or a sensitive part of his hand, to determine if the heat is 
sufficient to avoid condensation. If the flame is very hot, or if the 
mirror is exposed to it during too long an interval, the silver, or 
other backing of the glass, is fused, and the instrument destroyed. 
Glass being a poor conductor of heat, there is less danger of melting 
the coating of the back if the glass itself is held toward the source of 
heat. 

The laryngeal mirror now being ready for introduction, it is 
held like a pencil, and without loss of time, which would allow the 
mirror to cool, it is carried into the throat in such a way as to avoid 
contact with the tongue and surrounding parts, so as not to cause 
nausea and retching. The back of the mirror is made to impinge 
upon the anterior surface of the uvula and to carry the latter upward 
and backward. The mirror is then turned so as to reflect the rays 
of light from the forehead-mirror into the cavity of the larynx, when 
an image of the interior of the larynx and the superior portion of 
the trachea will come into view. The patient should be told that no 
pain will be caused, and that he should remain perfectly passive and 
breathe quietly. If he is able to accommodate himself to the situa- 
tion, an opportunity is given to study the vocal cords, which are 
seen in an abducted relation, of a white color, about three-fourths of 
an inch (two centimetres) long, and diverging from the upper to the 
lower ends, as seen in the reflected image (Plates I and IV). 

If the subject is caused to utter a broad, open sound, repre- 
sented by the syllable "ah," as used by vocalists in developing their 
voices, the vocal bands approximate each other and become parallel, 
with only a narrow slit intervening between them. As seen before 
vocalization, the vocal bands are concealed largely from view by the 
ventricular bands, only their borders being then visible. 



254 DIFFICULTIES OF LARYNGOSCOPY. 

One should not forget that he is not looking directly at the con- 
tents of the larynx, but at an image of them in a mirror, which, of 
course, reverses the picture to the observer; or, in other words, the 
examiner sees the picture as he would if his eye were behind and 
above the larynx, — the position occupied by the mirror. The epiglot- 
tis appears in the upper section of the mirror as a yellowish-pink 
valve, showing on its surface a map of minute blood-vessels. Its out- 
line is suggestive of a Cupid's bow, with the convex surface directed 
upward. Just below this bow is seen the anterior commissure of the 
vocal cords, which is narrower than the posterior commissure, as 
shown in the lower part of the image. The right vocal band appears 
in the left field of the image and the left is reflected in the right side 
of the picture. From the right and left termini of the bow-shaped 
borders of the epiglottis spring the aryepiglottic folds, curving grace- 
fully inward to meet each other in the form of a horseshoe, and com- 
pleting the superior boundary of the opening into the larynx by their 
union in the arytenoid commissure (Plate IV). On either side of the 
junction of the aryepiglottic folds is a nodular eminence called the 
cartilage of Santorini, and immediately to the outside of these knobs, 
on either side and slightly elevated above them, is a bulbous-appear- 
ing prominence, — the cartilage of Wrisberg. These eminences are of 
a redder hue than the epiglottis. Below them are seen the ventric- 
ular bands, which spring from an area corresponding to the junction 
of the cartilages of Santorini and Wrisberg (Plate IV, Fig. 9). 

The junction of the ventricular bands in front, their anterior 
commissure, is concealed by an eminence, — the cushion of the epi- 
glottis. The vocal bands or cords appear below the ventricular bands, 
extending from below the cushion of the epiglottis to points just 
inferior to the cartilages of Santorini. Between the ventricular 
band and vocal cord is a dark aperture termed the ventricle of the 
larynx. Beyond all these structures appear the rings of the trachea. 
From three to six are usually in sight, and sometimes a view of the 
whole length of the trachea to the branch of the right bronchus is 
obtained. For the anatomy of the larynx see Plate V. The various 
images resulting from correct and incorrect methods of examination 
are illustrated in Plate VI. 

Difficulties of Laryngoscopy. 

Laryngoscopic examinations are not without considerable ob- 
stacles in many instances. Although there are individuals with 



DIFFICULTIES OF LARYNGOSCOPY. 255 

capacious throats devoid of sensitiveness, who readily co-operate so 
as to afford a broad-gauge view of the interior of the larynx and 
trachea, there are frequently persons who have little or no control 
of their muscles, and who retch and gag, and even vomit, when an 
attempt is made at laryngoscopy. In such cases it may become 
necessary to inure the throat to the presence of foreign bodies by 
the practice, on the part of the patient, of inserting smooth, blunt 
articles, such as spoon-handles and the like, daily at home. In this 
manner a tolerance of instruments may be cultivated to such a degree 
as to render successful subsequent attempts at an examination. 

When repeated efforts fail on account of hypersensitiveness of 
the throat, it is necessary to bring to our aid a 4-per-cent. solution of 
cocaine or eucaine. This is painted over the base of the tongue and 




Fig. 87. — The Author's Epiglottis Retractor. 



the soft palate, and in a few minutes the sensibilities of the nerves 
are so benumbed as to permit of a thorough inspection with the 
mirror. 

Another instance in which it may become necessary to employ 
a local anaesthetic is when the epiglottis is pendent to the degree of 
obstructing the rays of light and preventing their penetrating the 
laryngeal cavity. In this condition the epiglottis must be raised and 
pressed forward out of the field of vision by a retractor (Fig. 87). In 
order to do so without producing pain and gagging the epiglottis may 
be treated to the cocaine solution. 

Fig. 87 illustrates an epiglottis retractor designed for use in cases 
in which it is impossible to obtain a good view of the interior of the 
larynx without holding the epiglottis upward and forward. The 
spade-like blade which rests on the posterior or under surface of the 



256 



DIFFICULTIES OF LARYNGOSCOPY. 



epiglottis is sufficiently wide to produce a certain degree of a flatten- 
ing effect on an omega-shaped epiglottis, thus facilitating laryn- 
goscopy in two ways. A firm control over the retractor is given by the 
employment of the double-ring handle, such as is used in the biting 
forceps. 

The tongue is often forced upward and shuts off the view if the 
mirror comes in contact with it and produces gagging. The patient 
is told not to strain, and the tongue is not drawn forcibly forward. 
If then the arching of the tongue does not recede, the tongue-de- 
pressor must be employed. If the mirror is held by the right hand, 




Fig. 88. — Position for Autoscopy. (Thorner.) This photograph was taken 

from a partly stripped patient in order to show distinctly the 

position of head and neck during examination. 



the tongue-depressor is held by the left in such a way that the in- 
strument intervenes between the thumb and the tongue, and the first 
finger rests under the tip of the tongue. The depressor must not be 
carried far enough backward to provoke nausea and retching. It is 
•better still to instruct the patient to hold his own tongue, so as to 
leave both hands of the surgeon free. 

When the tonsils are enlarged they so encroach upon the lumen 
of the cavity as to interfere with a satisfactor}> larvngoscop}'. Then 
a small mirror must be resorted to; but tonsils sufficiently hypertro- 
phied to embarrass an examination of the larynx ought to be clipped. 



DIRECT LARYNGOSCOPY. 



257 



Direct Laryngoscopy. 

Max Thorner has called the attention of American laryngologists 
to a method of examining the larynx and trachea without the laryn- 




Fig. 89. — Tongue-depressor for Pharyngoscopy and Direct Laryngo- 
tracheoscopy. (Thorner.) Side-view and surface-view of the anterior 
portion. In some cases an instrument with a larger curve of the anterior 
portion is more practicable. 

goscopic mirror. In a paper on this subject in The Laryngoscope for 
February, 1897, and in a translation of a monograph by Alfred Kir- 




Fig. 90.— Tangential Plane. (Thorner.) 

stein, of Berlin, on "Autoscopy of the Larynx and Trachea/' 1897, 
the method and instruments are described and illustrated in detail 

17 



258 



DIRECT LARYNGOSCOPY. 



The method consists essentially in pressing the tongue forward 
and downward until the axis of the laryngotracheal tube and that 
of the buccal cavity coincide with each other. This is effected, first, 
by having the patient incline the upper part of his body a little 
forward, and the face slightly upward, with his mouth open (Fig. 
88). The garments about the neck should be loose, and if false 
teeth are worn they must be removed before the introduction of the 
specially constructed spatula or the electroscope. Second, the phy- 
sician, standing before the patient, passes the spatula, having a down- 
ward curve at the inserted extremity (Fig. 89) behind the circum- 




Fig. 91. — Standard Spatula {8), Attached to the Electroscope, and Intra- 
laryngeal Spatula {&'), both with Hoods Omitted. (Thorner.) 

vallate papillae, and downward to the root of the tongue. The epi- 
glottis is then elevated by the method described in 1879 by Reichert: 
"Pressure upon the base of the tongue and the median glosso-epi- 
glottic ligament produces an elevation of the epiglottis on account 
of its close attachment to the tongue." 

So, with the patient in the position described, and the spatula 
introduced, the tongue is pressed downward and forward, the epi- 
glottis at the same time is brought upward and forward until a 
straight line in the groove of the autoscope coincides with the longi- 
tudinal axis of the laryngotracheal canal (Fig. 90). This brings the 



DIRECT LARYNGOSCOPY. 



259 



cavity of the larynx and the trachea to the bronchial bifurcation 
into direct view. The posterior wall of the larynx is easily inspected, 
but the anterior commissure, the ventricles of Morgagni, and the pyri- 
form sinuses are not within range of vision, and must be left for ex- 
amination with the laryngoscopic mirror. 

A prerequisite to successful "autoscopy" is that the rays of light 
be projected from the forehead into the throat, preferably by the 
electric head-light or by the electroscope (Fig. 91). The latter is 
a modification of Casper's instrument for inspecting the urethra. It 
has a handle containing an electric lamp, and a lens which focuses 
the light upon a prism, which, in turn, deflects the rays 90 degrees. 




Fig. 92. — Types of Instruments for Autoscopic Operations. (Thorner.) 



The light is reflected in this manner along the spatula of the elec- 
troscope into the laryngeal cavity. The examiner looks over the 
prism and sees the contents of the larynx and trachea directly, just 
as he sees the nasal cavities in anterior rhinoscopy. 

While it is not claimed by Thorner or Kirstein that this method 
should supplant the use of the laryngoscopic mirror, they assert for it 
certain advantages, which may be summarized as follow: Direct 
laryngoscopy gives a more realistic view of the organs inspected, in 
regard to boxh the normal color and the absence of reversal of the 
picture, both of which are important considerations in operative 
procedures; the posterior wall of the larynx and the deep portion 
of the trachea are subject to inspection; operations on the larynx 



260 DIRECT LARYNGOSCOPY. 

and trachea are performed with greater exactness and facility under 
direct linear inspection. 

Thorner regards this method of direct laryngoscopy "the most 
important addition to our technical resources since the discovery of 
the laryngoscope by Garcia." It is evident that the obliteration of 
the obtuse angle formed by the intersecting axes of the buccal cavity 
and the laryngotracheal tube, by rendering these axes . coincident, 
calls for instruments without the curve that characterizes those com- 
monly employed. Operations by the new method require that in- 
struments be constructed after the types shown in Fig. 92. 

Inspection with the autoscope — an unfortunate choice of name, 
since it is likely to be confounded with the word otoscope in speak- 
ing — necessitates monocular vision. About 50 per cent, of patients 
cannot be examined by this method. It requires considerable self- 
possession on the part of the patient as well as much practice on the 
part of the surgeon. Both Kirstein and Thorner concede that it 
should supplement, but not supplant, the use of the laryngoscopic 
mirror. 



CHAPTEE XXI. 
DISEASES OE THE LAKYNX (Continued). 

Acute Lakyxgitis. 

Synonyms. — Acute catarrh of the larynx; spurious croup. 

Pathology. — Acute inflammation of the mucous membrane lining 
the laryngeal cavity (Plate VI) is characterized by an engorgement 
of the blood-vessels, — an hyperemia, — accompanied, at first, by dry- 
ness of the membrane and afterward by an exudation of serum upon 
the mucosa, mixed with undeveloped epithelial cells and white cor- 
puscles. The thin, translucent secretion soon gives place to a more 
copious secretion of a thick, opalescent, mucoid character, studded 
with desquamated epithelium, pus-corpuscles, and traces of blood. 
Points of denudation of the mucous membrane are generally present, 
but the submucosa is rarely invaded by ulceration in this affection. 

Etiology. — Exposure to cold is the most common cause of this 
inflammation. Sudden changes from warm, ill-ventilated apartments 
to a cold, damp, or wind} 7 atmosphere when the subject is in a per- 
spiration or insufficiently clad are frequently followed by laryngitis. 
This is most commonly seen during the changes of the seasons from 
fall to winter and from winter to spring. The inhalation of irritating 
gases such as are often generated in laboratories may excite a catar- 
rhal condition of the larynx. Dust of certain kinds is a causative 
factor. Persons riding over the alkali deserts or plains of the west- 
ern part of the United States are sufferers from rhinitis, laryngitis, 
and conjunctivitis, occasioned by the irritating effects of the great 
quantities of alkali-dust in those regions. Overtaxing the voice and 
its improper use by singers and speakers induce attacks of acute 
laryngitis. Instances of this affection are very common during polit- 
ical campaigns, when stump-speakers are driven from the field by the 
inordinate use of their vocal organs. Firemen — who shout in the 
heat and smoke of burning buildings, and who often inhale much 
of the hot air, steam, and smoke — are subject to this disease. The 
uric-acid diathesis, rheumatic and gouty conditions, and the eruptive 
diseases stand in a causative relation to acute laryngitis. 

(261) 



262 ACUTE LARYNGITIS. 

Symptomatology. — The premonitory symptoms of acute laryn- 
gitis may be so vague and trivial as to scarcely arrest the attention 
of the subject. A slight feeling of dryness, as though the air inhaled 
were devoid of moisture, and, therefore, irritating, is generally the 
first unusual condition noticed. This is likely to be followed by a 
scratching or tickling sensation that excites efforts to relieve it by 
clearing the throat or coughing, which, instead of relieving the irri- 
tation, only adds to the feeling of roughness. A sense of constriction 
or of soreness soon follows, but palpation of the larynx seldom de- 
velops tenderness, except in rheumatic attacks. As the disease pro- 
gTesses and the vocal cords become involved, the voice changes in 
quality, or timbre. It takes on a rough, husk}', or hoarse, character, 
which has the effect of apparently lowering its pitch. 

About this time discomfort in swallowing occurs, amounting to 
a very painful effort. This is especially the case in the rheumatic 
form of the disease, and with the accentuated painfulness of degluti- 
tion may come a complete loss of voice, so that the only speech pos- 
sible to the patient is a forced whisper. Cough is not necessarily 
a symptom of acute laryngitis, but is frequently present. Its hoarse 
character is indicative of the location of the causative lesion in the 
larynx. Auscultation of the larynx will demonstrate the presence of 
mucous rales. These are not heard during the initiatory stage, in 
which the mucous membrane is dryer than it is in the normal state; 
but later, as the serous exudate and mucus bathe the walls of the 
larynx, the passing of air through these fluids gives rise to easily 
detected rales. The expectoration is characterized by the presence 
of the secretions just mentioned, and later in the disease by the pres- 
ence of pus, possibly streaked with blood. The presence of blood, 
however, is generally an accidental and unusual feature, being the 
result of a very violent fit of coughing, or, perhaps, of vomiting. 

Acute laryngitis does not usually give rise to very serious gen- 
eral disturbances of the system in adults, but it often presents alarm- 
ing symptoms in children. As all diseases produce a more profound 
impression during the early years of life than in adults, so acute 
laryngitis may evoke such violent symptoms as to fill the patient 
and friends with terror. The temperature rises; the pulse becomes 
accelerated, bounding, and hard, and the tongue is heavily coated. 
Even when the little patienl appears during the day to have no 
serious sickness, he may awaken at night with a suffocative attack out 
of all proportion to the apparent cause. The respiration is emibar- 



ACUTE LARYNGITIS. 263 

rassed and the respiratory effort is marked by an audible, stridulous 
sound. The cough reveals a changed voice, hoarse and husky, and 
the diminished ox} r genation of the blood and the frantic efforts to 
overcome the obstruction to breathing brino- on a swollen and con- 
gested appearance of the face. 

These attacks are sometimes called stridulous laryngitis, and 
they are probably occasioned by the drying of accumulated discharges 
in the glottis. The child breathes through his open mouth, with the 
result that the air entering the larynx and lungs is not moistened by 
the secretions of the nose, as it is in normal respiration. Conse- 
quently the dry air causes rapid evaporation of the water of the 
laryngeal secretions, with the effect of causing them to dry upon the 
vocal cords until they offer a positive obstacle to the current of in- 
spired air. When the obstruction has existed long enough to cause 
actual distress the patient awakens in a frightful state of impending 
strangulation. Soon, however, the active efforts of the patient to 
dislodge the inspissated secretions relieve the stenosis and restore free 
respiration, when calm succeeds the storm. 

The attacks described here have been attributed by some authors 
to a spasm of the adductors of the vocal bands. This spasmodic con- 
traction may play a role as a complication, but the mechanical ex- 
planation is reasonable; all the elements requisite to the production 
of such attacks are present; and it so conforms to our experience with 
similar conditions in other situations as not to necessitate an exercise 
of the imagination to account for all the phenomena observed. 

Inspection of the larynx during an attack of acute inflammation 
reveals a mucous lining of a bright-red color (Plate VI). The con- 
gested condition may be limited to various portions of the membrane, 
but usually it is diffused over the whole surface. There is a tumefied 
condition in severe forms of inflammation, and the ventricular bands 
may be so swollen as to override the true vocal bands and nearly 
occlude them from view. Then they are seen as slight, reddened 
lines below the ventricular bands. Ulcerations are not frequently 
seen, but small spots of the membrane denuded of its epithelium may 
be present. The epiglottis may participate in the inflammation, as 
shown in Plate VI, or it may not be involved. 

(Edema occurring in the course of laryngitis constitutes a grave 
complication, since it may give rise to fatal stenosis (Plate VI). 

Diagnosis. — In adults no serious difficulty to a diagnosis presents, 
in view of all the symptoms related. It is not likely to be confounded 



264 ACUTE LARYNGITIS. 

with diphtheria except in children, when it may be mistaken for 
true croup. In case of doubt, an examination of the fauces will likely 
reveal false membrane if diphtheria is present. A laryngoscopic ex- 
amination should be had if obtainable. The secretions should be 
subjected to bacteriological examinations if there is reason to suspect 
diphtheria. However, this disease does not run such a course as does 
diphtheria and it is not attended with the symptoms of profound 
sickness comparable to those of diphtheria. 

Prognosis. — This disease is of short duration and yields readily 
to proper treatment. 

Treatment. — ■ Local remedies are useful as detergents, astrin- 
gents, anaesthetics, protectives, and tonics. A spray of a mild alkaline 
solution with antiseptic properties, such as Dobell's, will dissolve 
and wash away the discharges, and, besides leaving the mucous mem- 
brane clear and free for the application of other medicaments, the 
effect is a very agreeable and soothing one. In the dry stage the 
author has found menthol ver} r efficient when inhaled in several dif- 
ferent ways. If no atomizer is at hand, the crystals can be fused in 
a teaspoon over a lamp or stove until the atmosphere of a small room 
is comfortably impregnated with the volatile fumes. The patient is 
directed to keep his eyes closed to prevent any smarting, and, unless 
his nostrils participate in the inflammation, he is instructed to breathe 
through the mouth. The inhalation starts a refreshing flow of mu- 
cus to bathe the parched membrane of the dry stage. Another ex- 
cellent treatment consists in putting 10 drops of pure camphor-men- 
thol into a half-pint of hot water contained in a hot-water inhaler 
(Fig. 22) or in a tea-pot or kettle, wrapping a napkin around the 
nozzle to prevent burning the lips, and then inhaling this medicated 
steam through the mouth with the lips embracing the nozzle. The 
hot, moist steam has an excellent effect, in addition to the action of 
the camphor-menthol, in contracting the capillary blood-vessels and 
producing a slightly anaesthetic and antiseptic effect. 

Cocaine and silver nitrate are recommended by some writers and 
are used much of tener than they ought to be. They are to be avoided 
in acute laryngitis. 

The writer has found his throat tablets useful, and they can be 
given freely, without producing any unpleasant consequences, except, 
perhaps, nausea. Each tablet contains 1 grain of ammonium chlo- 
ride and the equivalents of 5 minims each of paregoric, compound 
syrup of squills, and syrup of Tolu, with o grains of extract of lico- 



ACUTE LARYNGITIS. 265 

rice. These are held in the mouth and allowed to dissolve slowly and 
trickle down the throat. Besides the desirable action of the ingredi- 
ents of this tablet on the mucous membrane of the throat, the licorice 
generally produces a laxative effect on the bowels. J. D. Arnold 
recommends, in the case of superficial erosions, the use of cocaine, 
followed by painting the laryngeal mucous membrane with a 1- or 
2-per-cent. solution of chromic acid. He employs the cocaine not for 
the purpose of anaesthesia, for this strength of chromic-acid solution 
is not painful, but to contract and deplete the blood-vessels, in which 
condition the action of the acid is more beneficial. 

If the inflammation is of a severe grade, the icebag (Fig. 194) is 
indicated. Leeches to the neck are sometimes employed, but cold is 
preferable. Counter-irritation by mustard, tincture of iodine, aqua 
ammonia, chloroform, etc., is useful. 

General treatment consists, first, in putting the patient in such 
a condition as is favorable to successful treatment. He need not 
necessarily be put to bed, but he had best remain in-doors for a few 
days, where the temperature is uniform and where he will not be ex- 
posed to those conditions that brought on the attack. In the dry, 
or first, stage, 1 / 6 or even 1 / 3 grain of pilocarpine is useful to stimu- 
late the sudoriferous and salivary glands to activity. This is a sub- 
stitute for the old-fashioned, dismal sweats that loom up in our 
memory of boyhood. Quinine — that much-abused remedy, given for 
almost every ill that afflicts our race — is of little or no use here, as 
far as my experience goes. One or two doses of morphia, 1 / 12 grain, 
combined with atropia, V G00 grain, and caffeine, 1 / 6 grain, have often 
appeared to greatly ameliorate, and even shorten, the attacks ma- 
terially. Irritants — tobacco-smoke, alcoholic liquors, etc. — must be 
forbidden. 

If oedema be found, the tissues affected must be scarified, to 
let out the contents. Should the tumefaction and stenosis be so great 
as to seriously embarrass respiration or threaten suffocation, trache- 
otomy must be performed. 

The rheumatic type of acute lar} r ngitis is attended with con- 
siderable pain and difficult deglutition, that require promptly acting 
remedies. Ten-grain doses of salicylate of sodium every two hours 
should be given until either the s} r mptoms begin to show signs of 
relief or the physiological action of the drug begins to manifest itself 
in stuffiness in the ears, diminished hearing, ringing noises in the 
ears, or gastric disturbances. Then the doses should be placed at 



266 ACUTE LARYNGITIS. 

greater intervals or discontinued until these transitory symptoms 
abate, and renewed again in smaller doses until after complete re- 
covery. A fresh preparation should always be made, like the formula 
given in the article on the treatment of rheumatic pharyngitis (page 
155). If the sodium salicylate disagrees with the stomach or produces 
serious aural symptoms, and more especially if the patient already 
has an affection of the ear, salicin should be substituted for the sali- 
cylate. I have seen 10 grains of salicin, taken every two hours, pro- 
duce prompt relief before the expiration of a day. This effect is 
hastened if the same doses of effervescing citrate of lithia are taken 
three or four times a day. Antipyrin is often very beneficial in this 
disease, and the same may be said of salophen and salol. 

Climate has a definite effect on the rheumatic form of laryngitis. 
I have known a patient suffering from it during a season of cold, 
humid, windy weather that prevailed along the Great Lakes Region, 
to go south, into a genial, warm, sunshiny climate, and recover from 
the attack, without medicine, after two days of life in the sunshine, 
so magic in their effects are climatic conditions. 



CHAPTEK XXII. 
DISEASES OF THE LARYNX (Continued). 

Ckoup. 

Synonyms. — Pseudomembranous croup; idiopathic membranous 
croup. 

Pathology. — The question of the identity or duality of croup 
and laryngeal diphtheria is still a mooted one. Excellent authorities 
differ on this subject. So scholarly an author as Sir Morell Mac- 
kenzie believed the two to be identical. Both diseases affect the mu- 
cous membrane, with the result of producing a false membrane. Both 
diseases attack the same organ, — i.e., the larynx. Both obstruct res- 
piration. In these three particulars there is a close similarity in the 
two diseases, but the author is not prepared to admit their identity. 
Croup is primarily an affection of the larynx; diphtheria is generally 
at first an affection of the pharynx, although it may, in a certain 
percentage of cases, develop primarily in the larynx. "In one hun- 
dred and fifty-one diphtheric cases the membrane was limited to the 
larynx only once. In eighty-eight the membrane appeared first in 
the larynx or simultaneously with that of the pharynx" (Xorthrup). 
Croup is more frequent in the country, while diphtheria is more 
prevalent in cities. 

In the opinion of the author, the wide differences between the 
unicists and dualists can be harmonized by recognizing what certainly 
appears to be pathologically and clinically true: that there are two 
varieties of membranous croup, the one diphtheric, the other non- 
diphtheric. "Out of two hundred and eighty-six cases of membranous 
croup, 80 per cent, were diphtheric and 14 per cent, were certainly 
not diphtheric" (Medical Record). 

True croup is an idiopathic disease; diphtheria does not arise 
spontaneously, independently, in isolated instances without inocula- 
tion or infection, directly or indirectly, from a previously existing 
case of the disease, as croup does. The latter is not a contagious, 
inoculable disease; diphtheria is pre-eminently so. Croup does not 
infect the whole system with a profoundly depressing and exhausting 

(267) 



268 croup. 

poison, causing paralytic sequels, as the diphtheria toxin evolved by 
the Klebs-Loffler bacillus does. The clinical pictures of the two dis- 
eases are similar in their mechanical effects upon the respiration and 
consequent deoxygenation of the blood, but from that point their 
histories are not parallel. Their divergencies are apparent to one who 
has had much experience in their treatment. He must recognize that 
we have a laryngeal diphtheria, on the one hand, and a true croup, 
on the other. Porter agrees with this view, that there is a plastic 
exudation in the larynx which is not diphtheric. 

This is a disease of childhood, and occurs most frequently about 
the second year, and from that to the tenth year. 

Croup is an inflammation of the mucous membrane, usually con- 
fined to that part of the larynx superior to the vocal bands, but it 
may extend to the trachea. It is attended with the formation of 
an exudate, or inflammatory lymph, that is deposited in the form 
of a fibrinous membrane on the epiglottis, the ventricular bands, and 
to a greater or less extent upon the vocal cords. This false membrane 
does not penetrate the epithelial layer to the submucosa as the diph- 
theric membrane does, but it can be peeled off without tearing the 
mucous membrane or leaving a rough, raw, and bleeding or ulcerating 
surface. If the inflammation extend to the submucosa the laryngeal 
muscles become involved, resulting in spasms or paralysis. 

Etiology. — This disease may arise primarily, without any dis- 
coverable exciting cause, or it may occasionally be secondary to in- 
juries, irritants, scarlet fever, measles, small-pox, etc. Exposure 
to cold and moisture, especially combined with strong winds, may 
give rise to attacks. I have not observed that the previous condi- 
tion of health exerted much influence for or against the production 
of croup. Healthy appearing children seemed to be as easily subject 
to it as those who were badly nourished. The author has had a con- 
siderable opportunity to study these subjects in his practice in con- 
nection with the children's departments of the South Side and of 
the West Side Free Dispensaries, and. while the children that, most 
easily succumbed to diphtheria and other diseases were the feeble 
and strumous, he has seen the fat and rosy children as often attacked 
by croup as those with impoverished systems. 

The chilling of children by exposing them to draughts of cold 
air; the unpardonable practice of leaving their thighs bare and ex- 
posed to cold, as is the almost universal custom: the earning or 
wheeling of infants bare-headed in the cold; allowing children im- 



croup. 269 

properly clad to sit about in the open air in chilly weather, and to 
run about the house morning and night in their bare feet in cold 
weather, and similar practices that encourage the shocking of the 
skin by cold and disturbing the balance in the circulation of the blood 
are all prolific causes of croup. 

Symptomatology. — The first thing that may be noticed is the 
hoarseness of the child's voice. Before any fever or subjective symp- 
toms develop the parents may notice the sudden change in quality 
of the voice, but some indisposition may show for several days before 
the attack. Next, a slight cough appears that accentuates the coarse 
timbre of the voice. Its pitch sounds much lower than normal. 
Soon there are signs of fever and complaints of not feeling well. 
If the little one is old enough to describe sensations, headache may 
be spoken of. 

The symptoms often develop with surprising suddenness. The 
child may appear well during the afternoon, and by 7 o'clock in the 
evening the voice changes to an unnatural hoarse quality, which may 
be overlooked by the untutored or careless until, two or three hours 
later, coughing and difficulty of breathing alarm them to the point 
of summoning medical assistance. With each inspiration now is 
heard the well-known crowing sound of croup. The temperature rises 
to about 103° F. as the night wears wearily on and the obstruction 
to respiration increases with the increasing false membrane. The 
true inflammatory character of the disease is apparent. The pulse 
is accelerated, bounding, and hard; the tongue coated; the skin hot 
and dry; the face red and puffed; and the secretions are checked. 
Unless relief is obtained by expulsion of some of the obstructing mem- 
brane the difficulty of breathing increases until the labor necessitated 
in aerating the lungs is pitiful in the extreme. The sound of the 
prolonged crowing inspiration and the lengthened expiration indicate 
the extreme narrowing of the chink between the vocal bands. As the 
blood becomes poisoned by the lack of oxygen the little one's face, 
flushed at first with a beauteous glow, takes on a bluish tinge that 
darkens as the world grows dark to the little sufferer, until, at last, 
a cyanotic hue announces the approach of death. 

If portions of the false membrane are expelled, more or less 
relief is obtained, and a respite experienced until more membrane is 
formed to take its place, when dyspnoea again ensues. Often the worst 
is over in twenty-four or forty-eight hours, but in other cases the 
duration mav be five or six days. 



270 croup. 

Diagnosis. — Membranous croup may be mistaken for laryngeal 
diphtheria, acute laryngitis, or laryngismus stridulus. 

It may be difficult sometimes to distinguish croup from diph- 
theria. In croup the constitutional disturbance is less profound than 
in diphtheria. Obstruction to breathing is really the principal symp- 
tom of croup. Slight catarrhal symptoms and indisposition may exist 
for several days before the attack of croup, but the diphtheric attack 
is sudden and accompanied with severer symptoms. Croup is neither 
infectious nor contagious; diphtheria is both. In nearly every case 
of diphtheria there is a false membrane in the pharynx, but this is 
not true of croup. The difficult breathing of croup appears suddenly, 
while that of diphtheria is more gradual and lacks the spasm of 
croup. No other member of the family or community catches croup; 
diphtheria spreads to others, and has paralysis as a sequel, while croup 
has not. In case of doubt a bacteriological examination should be 
made. 

Acute laryngitis resembles croup in some respects, but it is at- 
tended by more pain in the larynx, less difficulty in respiration, and 
by no formation of false membrane. Croup is a disease of childhood, 
while laryngitis is generally confined to later years. The peculiar 
crowing sound of croup does not occur in laryngitis. The cough of 
the two diseases differs, that of croup having a deeper hoarseness and 
not being so short and hacking as in laryngitis. 

Laryngismus stridulus does not present the symptoms of sickness 
like croup. There is no fever and the labored respiration comes on 
quickly and subsides in a few minutes. The voice remains normal 
between the attacks. 

Prognosis. — Membranous croup is a very fatal disease. Statistics 
show that considerably more than half of the cases die, — 60 to 70 
per cent. Since the introduction of intubation of the larynx by 
O'Dwyer the death-rate has very materially decreased. In a col- 
lective investigation made by Eanke concerning intubation in Ger- 
many he reports 1445 cases intubated for croup, with 553 recoveries, 
or 38 per cent. 

O'Dwyer (New York Medical Journal) claimed that the "mortal- 
ity of laryngeal diphtheria without treatment is 90 per cent., which 
can be reduced to from 27 to 47 per cent ." 

Attacks of great severity may progress rapidly to a fatal termina- 
tion, the end beinu- induced by a spasm of the glottis occurring in 
a few hours from the seizure. In others the larynx gradually fills 



croup. 271 

with the false membrane, depriving the lungs of air until carbonic- 
acid poisoning, coma, and death occur. 

Treatment. — A patient with croup should be kept in a moist at- 
mosphere. I have made it a rule to put the child in a room contain- 
ing a stove, when it is possible. Then, large vessels, like dish-pans 
or boilers, should be placed on the stove and just enough water poured 
in them to cover their bottoms and keep them from burning. Wet 
sheets are hung about the stove, a hot fire is kept up, and in this way 
the atmosphere of the room is maintained saturated with steam, and 
at a temperature of 76° or 80° F. If there is paper on the walls, 
it will, of course, be spoiled. 

Unslaked lime is sent for, a bushel or more. A lump as large as 
a man's head is placed in a wooden bucket containing about two 
quarts of hot water. As chemical combination takes place an abun- 
dance of steam is generated which is conducted to the patient's head 
by a tent-shaped arrangement of a sheet. 

In the first, or catarrhal, stage counter-irritation is useful over 
the larynx by means of mustard. An icebag (Fig. 194) may modify 
the intensity of the inflammation. Gottstein advises not only these, 
but the use of leeches on the upper part of the sternum. 

Glasgow uses a spray of hydrozone thrown directly into the 
larynx. He believes the mechanical effect of the effervescence pro- 
duced is to detach the. false membrane and facilitate its expulsion. 
For the purpose of increasing the secretion of mucus, which has a 
similar effect, menthol crystals may be employed by fusing a few in a 
teaspoon over a flame until the air is comfortably impregnated with 
the fumes. Inhalations of vinegar are highly recommended by some 
writers. 

Calomel, both internally and externally, has proved a valuable 
remedy. It is believed to be potent in preventing the formation of 
an exudate. It increases the secretions, which action in itself con- 
tributes to the casting off of the false membrane. J. Dundas Grant 
reports favorable results from 1-grain doses every four or six hours. 
With each dose he combines 3 to 5 drops of wine of ipecacuanha and 
3 to 5 grains of bromide of potassium. I have for a long time been 
satisfied that calomel was efficacious, and have employed it in smaller 
doses more frequently administered, 1 / 2 grain every two hours, until 
the bowels were considerably relaxed. I use the sodium bromide in 
preference to the potassium because it contains a larger percentage 
of bromine and is not so vitiating to the blood. 



272 croup. 

Fruitnight, in the Archives of Pediatrics, has called timely atten- 
tion to the value of calomel fumigations in croup, whether looked 
upon as simple or specifically diphtheric. This treatment was 
originally suggested some years ago by Corbin, of Brooklyn, and later 
recommended by Dillon Brown. It should be used when there are 
symptoms of serious laryngeal involvement. "The amount of mer- 
curial salt to be vaporized varies from 5 to 20 grains, repeated at 
intervals varying from one-half to two or three hours, according to 
the severity of the symptoms; in the average cases 15 grains hourly. 
The patient is to be kept in the vapor-saturated atmosphere, within 
a tent, for a period varying from ten minutes to one-half hour. In 
one hundred cases thus treated no case has been subject to deleterious 
results. In one case only did slight ptyalism occur. Salivation, diar- 
rhoea, depression, prostration, and anaemia must be prevented by 
watchfulness and proper treatment." ("Year-book.") 

Emetics play an important role in the urgent stage of croup. 
When the larynx is filling to the degree of threatening suffocation 
a prompt emesis will often loosen the false membrane and effect its 
expulsion. To accomplish this I have most often used turpeth min- 
eral (yellow sulphate of mercury) and with the most gratifying re- 
sults. One or two doses will produce vomiting in a few minutes and 
afford marked relief. Ipecac, alum, and sulphate of copper are ef- 
ficient. I have never tried the last of these three. One should guard 
against the tendency of parents or nurses, or wise and more meddle- 
some neighbors, to overdose children with emetics, on account of the 
exhaustion and the irritability of the stomach which they produce. 
When these measures fail, intubation or tracheotomy must be done. 

Children who are recovering from this disease have very sensitive 
throats and must be protected against cold air and draughts. They 
should be clothed throughout in woolen garments, and kept in-doors 
until a normal condition of the larynx is re-established. Sprays of 
cubebs, camphor-menthol, lavolin, pine-needle oil, oil of tar, etc., will 
assist materially in a complete restoration of the mucous membrane 
to a state of health. 



CHAPTER XXIII. 
DISEASES OF THE LARYNX (Continued). 

Intubation of the Larynx. 

To Joseph O'Dwyer, of New York, is due the credit of intro- 
ducing the operation of intubation, which is now so commonly per- 
formed. Bouchut, of Paris, demonstrated in 1858 that the operation 
was practicable, but no practical results followed his discovery until 




Fig. 93. — O'Dwyer's Intubation-tubes. 



Fig. 94.— Scale. 



O'Dwyer, without knowledge of Bouchuf s work, showed actual re- 
coveries due to it. 

The instruments for this procedure are a set of tubes of varying 
calibre, with a scale for measuring the tube, to assist in selecting the 
proper size; a mouth-gag (Fig. 72); an introducer; an extractor, 
ar.d a protector for the surgeon's finger. 

The tube (Fig. 93) is constructed with a flaring top that rests 
upon the ventricular bands. On one side of the flange is an aperture 
through which a loop of thread sixteen inches long is passed before 
introduction, in order that, if the tube accidentally passes into the 
oesophagus, instead of the larynx, it can be withdrawn. The ob- 
struction of the tube with particles of membrane may also render it 

18 (273) 



274 INTUBATION OF THE LARYNX. 

necessary to draw the tube out by the thread. It is safest to employ 
a strand of braided silk or linen thread, being certain that it con- 
tains no inequalities to catch in the fenestra. 

The scale (Fig. 94) is used to determine the size of the tube 
to be employed, according to the age of the patient. 

The introducer (Fig. 95) is screwed into the obturator of the 
tube, as shown in the illustration, and, when the tube is inserted into 
the larynx, pressure on the button of the introducer separates the 
obturator from the tube, leaving the latter in the larynx while the 
obturator is withdrawn. 

The extractor (Fig. 96) is so constructed that, when the blades 
at the curved extremity are introduced into the mouth of the tube, 
pressure on the lever will separate the forcep-blades. These are 
roughened so that they obtain a grip that insures the extraction of 
the tube when they are withdrawn. 





Fig. 95. — O'Dwyer's Introducer, with Tube Attached. 

In addition to these instruments, one needs a protector against 
being bitten during the operation. J. E. Ehodes (Journal of the 
American Medical Association) reports that he has "devised a protector 
which consists of a rubber glove that covers the hand from the 
wrist to a little beyond the metacarpophalangeal joints. On the in- 
dex finger the terminal phalanx only is left uncovered." 

In order to prevent infection through the coughing of a patient 
while the operator occupies a position in front of his mouth, it is 
altogether safest to protect the eyes with glasses and the mouth and 
nose with a respirator or kerchief. 

The operation is a very brief one. not extending over ten seconds. 
The quicker it is accomplished, the less it interferes with respiration, 
and, therefore, with aeration of the blood. One should acquire not 
only extreme dexterity, but gentleness, in order not to do unneces- 



INTUBATION OF THE LARYNX. 



275 



sary damage to the delicate structure encroached upon. With proper 
skill one should inflict no injury nor seriously interrupt breathing. 
In selecting the tubes it should be remembered that the smallest is 
intended for children younger than 2 years, the next size for those be- 
tween 2 and 4, the third size for those between 4 and 6, the fourth for 
those from 6 to 8, and the largest for those over 8 years of age. 

After the tube of proper size, according to the age of the child, 
as indicated on the scale, has been chosen, it is attached to the in- 
troducer by screwing the latter into the obturator contained within 
the tube, with the short side of the tube toward the handle, as shown. 
The tube is threaded as already described, and the instrument is laid 
within easy reach of the right hand. Now, the child should be placed 
upon the lap of the nurse or assistant and held as shown in Fig. 73, 
illustrating the operation for removing adenoid vegetations from the 




O'Dwyer's Extractor. 



vault of the pharynx. The position assumed in the direct examina- 
tion of the larynx, or autoscopy, would be a good one for intubation 
if it could be secured (Fig. 88). A strong sheet is wrapped and 
fastened about the child, so as to prevent any freedom of movement 
of its arms and legs, the latter being held between the nurse's knees. 
The nurse passes her left arm around the child's left side and over 
its arm,, crosses the little one's wrists, and holds its right hand with 
her left and its left hand with her right, thus making it impossible 
for the child to interfere with the surgeon's work. One assistant 
places, the mouth-gag, as shown in the figure referred to, with the 
gag resting between the molar teeth of the left side. He must at- 
tend assiduously to the holding of the gag in place and keeping the 
child's head, thrown a little backward on the nurse's shoulder, im- 
movably fixed. If these directions are efficiently followed there can 



276 INTUBATION OF THE LARYNX. 

be no kicking, sliding down, snatching of the instrument, or disloca- 
tion of the gag. 

The introducer, with tube and obturator attached and previously 
warmed, is then taken, the thread loop is passed over the left little 
finger, and the left index finger, being oiled, is carried into the 
pharynx until its tip rests behind the epiglottis and holds it upward. 
Now the end of the tube is made to follow the course taken by the 
tip of the inserted finger until it rests directly beneath it. The tip 
of the finger readily recognizes the epiglottis and the opening be- 
tween the arytenoid cartilages. The instant the end of the tube rests 
beneath the tip of the finger in the median line, the handle of the 
introducer is brought upward so as to pass the tube from this point 
straight downward into the larynx. Unless this latter direction is 
followed at this particular step of the operation the tube will pass 
back of the larynx into the oesophagus. The tube once in the larynx, 
the thumb pushes the button and the tube is released, the introducer 
withdrawn, and the finger still in the throat presses the tube down 
into proper position. 

The surgeon should not neglect the use of a finger-guard and 
some protector for his eyes, mouth, and nose during the introduc- 
tion of the tube. A bite of the child or the ejection of a diphtheric 
discharge may cost the operator his life or communicate the disease 
to others. 

Before introducing the tube it should be examined to see if the 
instrument works easily, if the tube is readily released, and if it will 
remain safely in position while it is being introduced. The larger 
the tube that can be used, the freer the respiration and the discharge 
of particles of membrane will be through it. 

The thread is best not removed from the tube directly after the 
insertion, for an increase in the embarrassment of the respiration may 
occur, indicating that either false membrane has been pushed along 
below the tube to block up its lower opening or that the lumen of 
the tube is obstructed by the presence of false membrane or secre- 
tions in it. In either condition the tube must be removed forthwith. 
So the thread loop is secured by attaching another thread to it and 
passing it around the child's neck, and his hands must be kept away 
from it. As soon as it becomes apparent that the operation lias 
fulfilled its purpose by affording freedom of breathing, the gag is 
reintroduced, the thread is cut, the finger-tip placed on the end of 
the tube to prevent its dislodgment, and the thread loop is with- 



INTUBATION" OF THE LARYNX. 277 

drawn, leaving the tube in position. If the operation has been suc- 
cessful, the patient, relieved of the horror of impending suffocation, 
now drops into a peaceful slumber, which must be encouraged, in 
order that nature may recuperate its waning strength and fortify its 
resisting-powers. 

Pellets of ice may now be allowed the patient to suck for quench- 
ing the thirst and to teach swallowing with the tube in place. Later 
a few drops of cold milk are given for the same purposes. 

Should the first attempt to introduce the tube fail, the child 
must not be exhausted by too immediate an attempt for the second 
trial. A little rest is always best, unless the dyspnoea is exceedingly 
urgent. If the intubation fails or is followed by no relief, trache- 
otomy is the last resort. The physician should always be prepared 
for this emergency by having the tracheotomy instruments at hand. 

A bottle of nitrate of amyl should be provided, for, in case of 
threatened collapse, the inhalation of a few drops of it may resus- 
citate the little patient. 

For the removal of the tube the patient is prepared the same as 
for its introduction. The extractor is carried down, under the guid- 
ance of the tip of the protected left index finger, until it is slipped 
into the opening of the tube, when the lever is pressed upon by the 
thumb, the forcep-blades expanded to engage the tube, and the in- 
strument is withdrawn with the -tube attached. One must not forget 
to keep up the pressure that holds the tube attached to the extractor, 
or the tube might drop back into the throat. Eemoval of the tube 
may be necessary to clear it of obstructions or to ascertain when the 
patient no longer requires it. Should it be necessary to reintroduce 
it, a second tube had best be at hand already attached to the in- 
troducer, so that, if great dyspnoea occur before one has had time to 
clean and thread the tube removed, the other one can be inserted 
without delay. In case no other tube is at hand Northrup advises to 
"thrust the obturator into the tube and take two turns of thread 
of any kind around the neck of the tube, gathering the two ends in 
the right hand as it grasps the handle. In this way the thread holds 
the tube to the obturator during the insertion, and when it is in the 
larynx unwinds from the shaft and is drawn away/ 7 

After the tube has been in the larynx for a quarter of an hour, 
and there are no indications that it will have to be removed, the 
loop of thread is cut, and, with the finger in the pharynx and rest- 
ing on the end of the tube the same as on its introduction, the string 



278 INTUBATION OF THE LARYNX. 

is withdrawn. Care must be taken not to disturb the tube in doing so. 
While the thread is in the mouth it excites nausea and retching. 

The tube is allowed to remain in the larynx for several days, 
sometimes five or six, but, as soon as it becomes apparent that the 
disease has progressed so favorably as to render its presence there un- 
necessary, it is extracted. Sometimes it is coughed out. 

In the course of three or four hours after intubation the larynx 
becomes accustomed to the presence of the tube; but if fluids are 
administered in a sitting posture they are almost certain to enter 
the larynx and excite violent coughing, which may expel the tube, 
or they may enter the lungs and cause pneumonia. The safest way to 
feed these patients is that proposed by Frank Cary, of Chicago, as 
follows: The patient is placed upon his back, with his feet elevated 
so that the axis of the body rests at an angle of forty-five degrees 
to the plane of the floor. The fluids are given through a tube 
or nursing-bottle in this position; then they do not gain entrance 
into the trachea. Solids do not enter the trachea. Custards, corn- 
starch, thick gruels, etc., are quite readily taken, and many children 
soon learn to eat and drink with the tube in position. 

Intubation is to be preferred to tracheotomy in children under 
5 years, particularly with an abundance of adipose tissue overlying 
the trachea. Parents more readily consent to this procedure than 
to an operation that involves the use of the knife. Intubation pro- 
duces less shock than tracheotomy, and the air is better prepared for 
contact with the mucous membrane below the trachea after intuba- 
tion than when it enters directly through the tracheotomy-tube. Xo 
anaesthesia is required for intubation, but it is generally necessary in 
tracheotomy, although I have operated without an anaesthetic in case 
of emergency. I have seen cases requiring tracheotomy in which the 
time necessary to produce anaesthesia could not be sacrificed, and, 
indeed, the carbonic-acid poisoning produced a sufficient anaesthesia. 

There are instances in which intubation fails because the tube 
cannot be retained in position, or sufficient nourishment cannot be 
taken to support the waning strength, or the tube becomes so clogged 
that it has to be removed repeatedly. In these emergencies trache- 
otomy will have to be brought to our aid. Intubation is not diffi- 
cult for the laryngologist, but one needs considerable practice in 
order to be reasonably sure of success. The best means of acquiring 
dexterity is to introduce a tube frequently into the larynx of a 
cadaver. In the absence of conveniences for this, the tube should 



TRACHEOTOMY. 279 

be many times introduced and extracted by means of substituting 
a band, preferably that of another, for the larynx. The tube should 
be placed completely out of sight in the hand while its aperture 
is sought for with the extractor. But it should not be forgotten that 
the passive hand differs somewhat from an obstreperous, struggling 
child. Intubation requires two assistants, and if possible, one of 
these should be able to remove the tube or to introduce it if it is 
necessary to remove it or if it is coughed up. So in case of intuba- 
tion it is important that skilled assistants be at hand for these ex- 
igencies. 

Tracheotomy is easier to perform, and can be done in extremi- 
ties without skilled assistants. If the tube becomes clogged the nurse 
can prevent suffocation by removing it and maintaining the opening 
free until the surgeon arrives. In these respects tracheotomy pre- 
sents advantages over intubation. In cities where skilled laryngolo- 




Fig. 97. — Roswell Park's Aluminium Tracheal Tube. 

gists are within easy calling distance intubation possesses superior 
merits. In the country, with all its unavoidable disadvantages, tra- 
cheotomy is hardly likely to be superseded. 

Tracheotomy. 

The instruments necessary for this operation are a small knife, 
double retractors (Fig. 205), haemostatic forceps, tracheal forceps, a 
tenaculum, a grooved director, a flexible catheter, and tracheotomy- 
tubes of various sizes (Figs. 97 and 98). The average size, up to 
3 years, is one-fourth inch (six millimetres). Other convenient arti- 
cles should be at hand, if circumstances permit of their being sup- 
plied: sharp-pointed forceps, an aneurism-needle, thread, absorbent 
gauze, and tapes. 

An anaesthetic should be given unless the requisite time would 
endanger life, or the diminution of the amount of oxygen reaching 



280 TRACHEOTOMY. 

the lungs would add to a danger already imminent, or unless the sen- 
sibilities are sufficiently obtunded by carbonic-acid poisoning. In 
this operation chloroform is to be given the preference over ether, 
on account of the effect of ether in exciting glottic spasm and in- 
creasing the difficult}^ of respiration. 

The high operation, in which the trachea is entered above the 
isthmus of the thyroid gland, is generally to be preferred to the low 
one, in which the incision is made below the isthmus, since in the 
high operation there are fewer and smaller blood-vessels to encounter 
(Plate V). Another advantage gained in the high operation lies in 
the more superficial position of the trachea. 

The position of the patient during the operation is upon the 




Fig. 98.— Hard-rubber Tracheal Tube. 

back, with the head thrown backward by means of a narrow support 
under the back of the neck, to force upward prominently the ante- 
rior surface of the neck. If the operation is done without anaesthesia, 
the head, hands, and legs must be held by assistants. 

The incision is made in the median line, over the cricoid car- 
tilage, for the high operation, extending an inch or more above and 
below the cartilage. The superficial anterior jugular vein may be 
met with at this point, and requires to be drawn out of the way or 
doubly ligated and divided; but, if there is need for great haste, it 
can be secured by haemostatic forceps until after the trachea is 
opened. The superficial fascia is opened, the grooved director in- 
serted, and the incision is completed, after which the deep fascia is 
similarly incised. The knife-handle is used to separate the sterno- 



TRACHEOTOMY. 281 

hyoid and the sternothyroid muscles; the self-retaming retractors 
(Fig. 205) are now inserted to keep the wound open and to check 
haemorrhage by their pressure on its sides. The rings of the trachea 
can easily be felt, and the isthmus of the thyroid gland may protrude 
sufficiently to necessitate its being drawn out of the way. A trans- 
Terse incision is now made, about one-half inch (one centimetre) long. 
over the superior border of the cricoid cartilage, penetrating the 
superficial layer of the deep cervical fascia. The grooved director is 
then introduced, passing from above downward between the cricoid 
cartilage and the deep layer of the deep cervical fascia. The two 
layers of fascia with the intervening veins and thyroid isthmus are 
drawn downward, exposing the upper rings of the trachea. These are 
fixed by the tenaculum and divided by an incision about one-half inch 
in length, according to the age of the patient. Great care must be 
taken that the knife does not penetrate the posterior wall of the 
trachea and the oesophagus. Equal forethought should insure that 




Fig. 99.— Tracheal Dilator. 

the false membrane is penetrated, so that the tracheal tube shall not 
be inserted between the membrane and the wall of the trachea, thus 
blocking up its opening. Care must be used to avoid the entrance 
of blood into the trachea and lungs. Coughing generally occurs 
when the trachea is opened, so that the secretions and portions of 
the false membrane are expelled. In case of diphtheria it is evident 
how necessary it is for the physician to be on the alert to dodge the 
bombardment of poisonous discharges. 

The trachea being opened, a dilator (Fig. 99) is employed by 
many surgeons until the haemorrhage ceases and free respiration is 
established. Sponging must be rapid; the opening must be main- 
tained free from discharges; all false membrane within reach of the 
tracheal forceps must be extracted, and, finally, the tracheal tube is 
introduced and secured by tapes passing around the neck and tied 
on one side. As large a tube as the trachea will admit should be 
used. The patient must be closely watched and, if necessary, arti- 
ficial respiration must be performed; clogging of the tube and in- 



282 TRACHEOTOMY. 

terference with it must be prevented. All the tissues about the wound 
should be cleansed with a solution of bichloride of mercury, 1 to 5000, 
and a divided piece of gauze, smeared with carbolized vaselin, should 
be interposed between the collar of the tube and the surface of the 
wound. 

The low operation is performed similarly to the one already de- 
scribed, except that the incision begins at the cricoid cartilage and 
ends about one-half inch above the sternum. The trachea lies deeper 
here; the blood-vessels are larger and more numerous and the thy- 
roid isthmus is in the way. It is a more difficult procedure. 

After tracheotomy the tube is best protected by a layer of bichlo- 
ride gauze kept loosely above and about the tube, without impeding 
the currents of air. As rapidly as it is soiled this protector should 
be removed. The air of the apartment is kept at a uniform tem- 
perature of 76° to 80° F., and impregnated with moisture to prevent 
irritation of the mucous membrane of the deeper air-passages. Dur- 
ing the first day the inner tube must be removed frequently for 
cleaning with a 5-per-eent. solution of carbolic acid, and to make 
certain that there is no obstruction. Sections of the false membrane 
may block up the lower end of the large, or outer, tube and require 
removing- with the tracheal forceps. In such an emergency the can- 
nula has to be removed. The nurse should always be instructed as to 
the possibility of such an accident, and that, should it occur, she 
must at once cut the tapes, remove the tube, cleanse and free the 
opening, and maintain its patency until the surgeon can be sum- 
moned. In two or three days the tube should be closed momentarily 
to determine if respiration is normal without it; if so, it can be dis- 
pensed with and the wound closed. 



PLATE VI. 



PLATE VI. 



Figure 10. — Imperfect view of the larynx resulting from an improper inclina- 
tion of the patient's head, or an incorrect position of the mirror. The head and 
mirror are not carried far enough backward. 

Figure 11. — The conditions are similar to those mentioned in the description 
of Figure 10, but with some improvement, giving a partial view of the laryngeal 
cavity. 

Figuee 12. — Omega-shaped larynx of a child. 

Figure 13. — Hyperemia of the mucous membrane of the larynx, not involving 
the vocal cords or the epiglottis. The vocal cords are in the position of phonation. 

Figure 14. — Congestion of the larynx involving the epiglottis, and the vocal 
cords to a slight degree. 

Figure 15. — Acute laryngitis involving both vocal cords. 

Figure 16. — Acute laryngitis involving the vocal cords and the epiglottis. The 
blood-vessels of the epiglottis are injected; there is an cedematous condition of the 
right half of the larynx. 

Figure 17. — Chronic laryngitis involving the vocal cords, which are ulcerated 
near the posterior commissure. 

Figure 18. — (Edema of the larynx; phlegmonous inflammation. 

Figure 19. — Tubercular infiltration of the arytenoid cartilages, with superficial 
ulceration of the interarytenoid fold and the vocal cords. 

Figure 20. — Tubercular infiltration of the larynx. The epiglottis is pale and 
greatly thickened, together with the arytenoid cartilages, which are pear-shaped. 
The depressions between the cartilages of Wrisberg and Santorini are obliterated. 

Figure 21. — Tuberculosis of the larynx; tumefaction of the arytenoid carti- 
lages; ulceration of the vocal cords, the left ventricular band, and the interarytenoid 
membrane. 



PLRTE VI, 




10 





12 





OF 



Cath ells Book on 

The Physician Himself 



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their careers, have been worth hundreds of times its price as an un- 
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GIVE THIS BOOK TO YOUR STUDENT 

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BOOR ON THE PHYSICIAN HIMSELF and 
Things THat Concern his Reputation and Suc- 
cess by D. "W. Cathell, M.D. Twentieth. Century 
(Eleventh) Edition, Royal Octavo, 4^1 Pag'es, 
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•o« ltwa 



CHAPTEE XXIV. 
DISEASES OF THE LARYNX (Continued]. 

Chronic Laryngitis. 

Synonym. — Chronic catarrh of the larynx. 

Explanatory Note. — Before entering upon a consideration of this 
subject it is pertinent to explain why there is no separate article in 
this book, as is customary, on subacute inflammation of the larynx. 
There are many varying degrees of inflammation of the mncons mem- 
brane. During the same attack of acute inflammation the process 
exhibits different degrees of intensity, but the tendency of our times 
has been too much toward useless and confusing refinements and 
multiplication of pathological conditions into entities, when they 
were really but modifications of the same disease; like shades of the 
same color, there are variations of the same malady. Formerly the 
mild grade of acute inflammation of the middle ear was described 
separately as a subacute inflammation, although it is not a different 
disease; but the leading books on otology now discard this adventi- 
tious distinction, and laryngologists should lend encouragement to 
a sensible simplification of a terminology which is encumbered with 
unwarranted parasites of nomenclature. So we will not attempt to 
multiply the varying grades of intensity of an acute inflammation 
into separate diseases. 

Pathology. — When acute laryngitis is neglected it naturally 
terminates in a chronic inflammation (Plate VI) which leaves the 
mucous membrane thickened and the small blood-vessels engorged 
and tortuous. There is an increase in connective-tissue formation, 
the encroachment of which on the epithelial layer produces the super- 
ficial erosions occurring in this disease. The posterior portion of the 
cavity only may be involved, or the inflammatory process may extend 
to every part of the larynx, not excepting the muscles. When the 
latter become indurated the mechanism of pitch-production is so in- 
terfered with as to render its changes very difficult. If the mucous 
membrane covering the vocal cords is thickened, the result is an 

(283) 



284 CHRONIC LARYNGITIS. 

alteration in the timbre or quality of the voice, which assumes a 
hoarse sound. 

Etiology. — As chronic rhinitis is the direct result of repeated 
or neglected attacks of acute nasal catarrh, so chronic laryngitis may 
be a sequel of recurring or neglected attacks of acute catarrh of the 
larynx. But this disease is not always a heritage of an acute attack. 
It often arises spontaneously. Many patients who are afflicted with 
chronic hypertrophic rhinitis present a chronic laryngitis as a com- 
plication or result of the nasal hypertrophy. This is easily under- 
stood when we take into consideration the continuity of mucous mem- 
brane of the larynx, pharynx, and nasal cavities. In addition to this 
direct cause is another which illustrates the importance of prompt 
and efficient treatment of nasal anomalies. The discharges from the 
nose and naso-pharynx constantly find their way either directly into 
the larynx by dripping into the cavity, or they gravitate down to the 
immediate vicinity of the portal of the larynx, where they cause direct 
irritation by their presence, and indirect irritation by exciting efforts 
to dislodge them with a hacking cough. Bosworth lays stress upon 
this source of chronic laryngitis. 

Another causative relation of hypertrophic rhinitis to this dis- 
ease lies in the forced mouth-breathing in consequence of nasal steno- 
sis. The air then reaches the larynx without the processes of purify- 
ing, warming, and moistening having been applied to it as they are 
by the nasal passages in a normal condition. 

Excessive use of the voice, especially when it is taxed beyond 
its natural or acquired compass, sets up an hyperemia and congestion 
that finally terminate in a chronic inflammation. Ambitious, but 
ill-trained singers, the periodical orators of political campaigns, huck- 
sters, intensely emotional revivalists, etc., are frequent sufferers. In- 
activity of the liver, and dyspepsia, alcoholic excesses, and atmos- 
pheric irritants are prolific producers of this disease. According to 
the observations of Ziemssen and Mulhall, boys are rendered sus- 
ceptible to attacks of catarrhal laryngitis by the changes incident to 
the age of puberty. 

Symptomatology. — The most marked symptoms are developed 
when attempts are made to use the voice. While it is at rest there 
may be very little to call the patient's attention to the fact that he 
has a larynx. In other instances there is a sensation of dryness or a 
slight irritation that excites a hemming or a little cough. But when 
the patient begins to call the vocal organs into activity the trouble 



CHRONIC LARYNGITIS. 285 

begins. A tickling sensation is experienced that produces an irre- 
sistible desire to cough. Burning and pricking pains are felt in the 
larynx, which one endeavors to relieve by clearing the throat. In 
the midst of a sentence a cutting pain shoots through the organ, 
that may be described as a feeling as though the vocal cords were 
splitting or tearing. The sentence, or even the word, is cut short, 
and for an instant the speaker is unable to proceed until he clears 
the throat or takes a drink; hence arises the habit of many speakers 
of providing themselves with a glass or a pitcher of water before be- 
ginning a discourse. 

The voice shows the most marked effect of this disease, but 
there are great variations in different patients, and peculiarities dis- 
tinguishing certain cases. When a speaker, for example, begins an 
address, his voice may be husky and cracked in quality, while, after 
proceeding for a short time, the normal timbre may be restored. 
Singers experience the same peculiarity. This is probably due to 
the increased secretion stimulated by a quickened circulation, as well 
as to improved innervation resulting from the intensity of will- 
impulse. Another characteristic is the natural quality observed in 
the customary tones and the breaking of this quality on straining the 
voice, and even a condition of complete aphonia, or loss of voice. 

The secretions are not copious in uncomplicated chronic laryn- 
gitis. They are generally tenacious and of a gray color, but if ulcera- 
tions are present they assume a yellow hue. As in the acute inflam- 
mation, there is rarely any blood in the expectorations, unless an 
unusually violent effort at coughing has ruptured the vessels. 

Inspection with the laryngeal mirror shows an hypersemic con- 
dition of the mucous membrane (Plate VI). As the figures illustrate, 
the small blood-vessels of the epiglottis are engorged and conspicu- 
ous. The vocal cords are sometimes red, one or both of them; at 
other times they do not participate in the inflammatory process. One 
cord may be affected, while the other remains of normal appearance, 
or parts only of the cords may show an injected condition of their 
blood-vessels. These parts are the lateral attached borders of the 
vocal bands. The condition of the membrane varies, according to 
the amount of secretions present, from absolute dryness to a general 
covering of the whole interior with secretions. Like similar condi- 
tions of the mucous membrane in other localities, a gradual thicken- 
ing of the mucosa and submucous tissues results from inflammation 
of long duration, and the vocal cords may be affected by this hyper- 



286 CHRONIC LARYNGITIS. 

plasia to the extent of granulation formation, or trachoma. The 
presence of these excrescences materially embarrasses the vibration of 
the cords and changes the character of the notes produced. 

The chronic thickening of the mucosa and the subjacent tissues 
diminishes the mobility of the larynx, just as we have seen that the 
increased thickness of the drumhead and of the tissues entering into 
the construction of the joints of the ossicles and the attachment of 
the stirrup to the oval window diminishes or destroys their mobility. 
For example of impeded movements due to hypertrophy: when the 
interarytenoid fold becomes thickened the arytenoid cartilages cannot 
approximate each other normally, which is equivalent to saying that 
the vocal bands cannot do the same thing. Great swelling of the 
ventricular bands obliterates the ventricles and deranges the actions 
of the vocal cords. One cord becomes paretic (Plate VII) and the 
opposite cord must do vicarious service, which it does by taking the 
place, almost literally, of its fellow, by moving across the median line 
to approximate its useless mate. The gap is then closed up, to a de- 
gree, and voice-production is made possible. 

Ulcerations of a shallow kind are occasionally to be seen, gen- 
erally in the interval between the arytenoid cartilages. 

Diagnosis. — Chronic laryngitis is likely to be confounded with 
laryngeal oedema (Plate VI), paralysis, and cancer, or syphilitic and 
tubercular laryngitis. In oedema the swelling of the mucosa is out 
of all proportion to the thickening of chronic inflammation, -and, 
although there may be redness, there is generally a pale, puffy, and 
water-soaked appearance, and the disease is of short duration. In 
paralysis neither swelling nor congestion is present. In the catarrhal 
condition hoarseness is generally more apparent in the morning hours, 
while the change in character of the voice in paralysis is constant, 
but less noticeable immediately after a night's rest. Paresis in the 
catarrhal condition more often affects one vocal band than both, ac- 
cording to Ziemssen; and the absence of mobility is much greater 
in paralysis. In catarrh the use of the voice often has the effect of 
clearing it of its cracked quality, while in paralysis fatigue and vocal 
exercise impair its quality. 

Tubercular laryngitis presents a very different history from that 
of the simple catarrhal disease. The general condition of the patient 
and the presence of a tubercular condition of the lungs assist ma- 
terially in making a differential diagnosis. The impaired nutrition 
and strength, the temperature and pulse, the night-sweats, and pain- 



CHRONIC LARYNGITIS. 287 

ful and difficult swallowing are characteristic of tuberculosis, but not 
of chronic laryngitis. The intralaryngeal pictures show certain dif- 
ferences in the two diseases. While redness is a symptom of catarrhal 
inflammation, the membrane in tuberculosis of the larynx may pre- 
sent a bloodless appearance, especially in the initiatory stage of the 
disease. Erosions, rare in simple catarrh, are characteristic of the 
tubercular affection. In laryngitis of the simple type, even when 
the erosions are found, they are superficial points of exfoliation of 
the epithelium; but in tuberculosis they may extend deeply into the 
membrane and be distributed over a wide area (Plate VI), affecting 
the epiglottis, the posterior commissure, the ventricular bands, and 
the vocal cords. The polypoid conformation of the arytenoid car- 
tilages produced by the great thickening in advanced cases is well 
illustrated in the plate to which reference is made. This swelling 
extends to the aryepiglottic folds and appears dense instead of cedema- 
tous, although the paleness of the membrane may be suggestive of a 
case of oedema. 

Syphilis of the larynx (Plate VII) may closely simulate a simple 
catarrh, but a syphilitic history or the presence of ulcers or their 
scars, and deformities due to the contraction of old cicatrices are 
valuable aids to diagnosis. The effects of the administration of spe- 
cific remedies in experimental diagnosis are determinative in syphilis. 

In both tuberculosis and syphilis of the larynx characteristic 
lesions in the pharynx may help greatly in arriving at a correct con- 
clusion. 

Chronic laryngitis may be with difficulty distinguished from a 
malignant disease, at first, but the histories of the two conditions 
vary. In the early stage of malignant disease the red, tumefied ap- 
pearance is limited to a certain area instead of being diffused over a 
large surface. As the neoplasm increases in size it changes the con- 
tour of the parts as simple catarrh does not, and difficult and painful 
swallowing, together with loss of voice, are marked symptoms of 
malignant disease. As deep ulceration in the latter condition takes 
place the pain is more pronounced and continuous than is met with 
in simple chronic laryngitis. 

Prognosis. — If the disease has not existed too long, and proper 
treatment and hygienic conditions can be had, the outlook is favor- 
able. But if thickening of the tissues is great and extends to the 
laryngeal muscles, the difficulties to overcome are considerable. This 
trouble is usually protracted and extends over many years, in some 



I 



288 CHRONIC LARYNGITIS. 

cases, and, after treatment has accomplished all it will, the voice may 
still retain a coarse, unpleasant quality. 

Treatment. — The topical application of remedies is easily accom- 
plished with the improved apparatus of our day. Compressed air and 
sprays can be made to apply medicaments to the interior of the larynx 
with ease and efficiency. Useful devices are shown in Chapter I 
for both office and home treatment. Improved appliances for com- 
pressing air, both by hand and hydraulic power, are described in Chap- 
ter XXXI. 

Various medicated sprays — as recommended by Lennox Browne, 
E. L. Shurly, Charles E. de M. Sajous, and others — will cleanse and 
disinfect the larynx, as well as produce astringent, sedative, stimu- 
lant, or tonic effects. It is claimed by Eoe and Cohen that sprays 
thrown into the throat are largely condensed in the pharynx, but 
it can be easily demonstrated upon one's own larynx that the remedy 




Fig. 100. — The Author's Medium Laryngeal Applicator. 



can be made to medicate that organ also. If the spray is thrown 
through a long tube with a properly curved extremity (Figs. 9 and 10) 
for directing the current downward and a little forward from a posi- 
tion similar to that occupied by the laryngeal mirror in sit:'., the 
spray enters directly into the larynx. When the nebulizer | used 
with the lips closed over the mouth- tube and the patient iAialing 
through the instrument, the medicinal vapor not only reaoAes the 
laryngeal cavity, but the bronchi and lungs also. In former years 
I used the complete steam-atomizer of Codman & Shurtlell', but, as 
I could not discover compensating advantages of the steam method 
over the improved apparatus referred to, and as the latter requires 
far less time and trouble in giving treatments, I have for a consider- 
able time preferred the instruments described. 

For the application of pigments to the laryngeal membrane spe- 
cial camel's hair brushes, sponges, and cotton are used. I prefer the 



CHRONIC LARYNGITIS. 289 

cotton, twisted firmly on short or long holders which afford a firm 
grasp (Figs. 100 and 101). The bristles of the brush sometimes be- 
come detached and stick in the larynx, like the voice of zEneas. 
This is not amusing to the patient. Applicators for caustics are spe- 
cially constructed, but, with a minute cotton-tip twisted very firmly 
on a carrier, escharotics can be conveniently applied. 

Counter-irritants, like mustard and tincture of iodine, are some- 
times serviceable. They should be applied to the skin directly over 
the larynx and at its sides. It is exceedingly important that the cause 
of the trouble be removed, and this will generally be found to lie in 
inordinate and improper exertion of the voice. In such cases absolute 
rest must be enjoined. When the cough is very troublesome the com- 
pound spirit of chloroform or Hoffmann's anodyne will relieve the 
irritation. The inhalation of camphor-menthol from the pocket- 
inhaler (Fig. 23) allays the tickling sensation. 



Fig. 101. — The Author's Long Laryngeal Applicator. 

When the thickening of the membrane is considerable, sprays 
of eucalyptol, 4 per cent.; camphor-menthol, 3 per cent.; or oil of 
cubebs, 4 per cent., in lavolin should be used once or twice a day. 
Alum, in a 2-per-cent. solution; zinc sulphate, 1 per cent.; or silver 
nitrate may be used according to the indications in each case. When 
much irritability exists, with a hacking cough and copious secretions 
and expectoration, inhalations of a 10-per-cent. solution of camphor- 
menthol in lavolin are effective. These should be taken through the 
nebulizer, and not in the form of a coarse spray. 

In cases of hoarseness and failure of the voice in public singers 
and speakers I have obtained most gratifying results from zinc chlo- 
ride, 10 or 20 grains to the ounce of water, and cupric sulphate, 15 
grains to the ounce, applied by means of the cotton applicator. In- 
halations of a vapor consisting of camphor-menthol, 10 per cent.; 



290 SUPPURATIVE LARYNGITIS. 

oil of cubebs, 50 per cent.; and benzoinol, 40 per cent., have aided 
materially in restoring the voice. 

If erosions are discovered, hydrozone, diluted one-half with warm 
water, at first, should be sprayed upon the ulcers; then aristol should 
be sprinkled over them. Iodoform is preferred by some, tannin and 
alum by others. Chromic acid, 5 or 10 grains to the ounce, and silver 
nitrate have able advocates. 



Atrophic Laryngitis. 

For the pathology of atrophic conditions of the mucous mem- 
brane, see "Atrophic Khinitis." 

This requires stimulating applications. The lavolin-sprays con- 
taining the remedies already given are useful, — viz., eucalyptol, oil 
of cubebs, benzoinated lavolin, menthol, terebene, salol, oil of tar, etc. 
Shurly recommends iodine in the form of syrup of hydriodic acid, 
in drachm doses, three times a day, or iodide of potassium or am- 
monium. Much relief is afforded by my ammonium-chloride tablets, 
the formula of which will be found on page 151. Two or three can be 
used in the course of an hour, being allowed to dissolve slowly in the 
mouth, so that the medicated saliva will trickle down and remain in 
contact with the mucous membrane about the entrance to the larynx 
as long as possible. 

Suppurative Laryngitis. 

Synonyms. — Phlegmonous laryngitis: purulent laryngitis; dif- 
fuse abscess of the larynx. 

Pathology. — This is an inflammation of the submucous tissues 
of the larynx (Plate YI), with infiltration of the areolar tissue and 
suppuration, ending in the formation of abscesses. The area most 
frequently involved is the superior part of the larynx, contiguous to 
the epiglottis. 

Etiology. — Suppurative inflammation of the larynx may be 
idiopathic, or it may arise secondarily by extension from the pharynx. 
It may originate in a perichondritis which is secondary to syphilitic 
infection or other wasting disease. 

Symptomatology. — Difficult respiration and impairment or sup- 
pression of the voice are the most prominent symptoms. There is 
a choking or stifling sensation, as though a foreign substance had 



ABSCESS OF THE LARYNX. 291 

gained entrance into the larynx, accompanied by increasing pains. 
Some difficulty in deglutition appears; all the symptoms become ex- 
aggerated; the breathing is strident, the voice feeble and cracked, 
the face puffed and purple, and suffocation seems imminent. Fre- 
quent attempts are made to free the throat by hemming rather than 
by coughing. Laryngoscopy reveals the inflamed, tumefied mucous 
membrane obstructing the air-current. Circumscribed swelling may 
be seen in the region of the aryteno-epiglottic folds, and other parts 
of the larynx may become (Edematous. 

Diagnosis. — Inspection discloses the differences between this dis- 
ease and the presence of foreign bodies, diphtheria, croup, tumors, 
pharyngeal abscess, and spasmodic croup. The dyspnoea of this dis- 
ease appears more gradually than that occasioned by the presence 
of foreign bodies or laryngismus stridulus, in which the obstruction 
to breathing occurs suddenly. The history of a tumor does not pre- 
sent the characteristics of an inflammation. 

Prognosis. — Suppurative laryngitis is a rapidly fatal disease. It 
kills about three out of four of its victims. Death is caiised by 
strangulation or inanition. 

Treatment. — If the patient is seen at the onset of the attack, 
cold, in the form of icebags (Fig. 194), should be constantly applied 
over the larynx. Pellets of ice may be sucked so as to produce the 
effect of cold internally as well as externally. Leeches may be applied 
over the upper portion of the sternum, but in this disease there is 
one objection to them that may not have weight in other diseases of 
the larynx, — i.e., the patient soon becomes exhausted from the lack 
of nourishment, owing to the impossibility of swallowing sufficient 
food, and bleeding only adds to his weakness. The air should be kept 
moist, the same as in croup. (Edematous tissue and abscesses must 
be evacuated by scarification. Supportive and stimulant treatment 
must be combined with nutritious enemata to meet the inevitable 
failure of strength. Suffocation must be prevented by tracheotomy or 
intubation. 

Abscess of the Larynx. 

The physical conditions in this disease coincide so closely with 
those just described under the heading of "Suppurative Laryngitis/' 
in which abscesses occur, that a separate description would be tanta- 
mount to tautology. The treatment is the same as for abscesses oc- 
curring in suppurative laryngitis. 



292 (edema of the larynx. 

Trachoma of the Vocal Chords. 

As a result of chronic laryngitis of long duration, a roughened 
condition of the vocal bands is found, to which the name "chorditis 
tuberosa," or granulations, is sometimes applied. There is a prolifera- 
tion of connective tissue, productive of inequalities that are apparent 
in the laryngoscopic image. This condition obtains most frequently 
in public speakers and singers and is sometimes quite intractable to 
treatment. F. I. Knight claims that the granulations may disappear 
without treatment. 

Treatment. — The remedies recommended for chronic laryngitis 
are applicable here. Charles E. de M. Sajous advises applying chromic 
acid to the cocainized hypertrophies. This is best accomplished by 
fusing the acid on a protected applicator, bent to the proper curve. 
Only a few of the prominent points should be touched at each treat- 
ment. Silver nitrate is preferred by Eice and Cohen, and the curette 
by Heryng. The biting curette (Fig. 102) or the electrocautery (Fig. 
108) may be adapted to certain cases. The writer prefers the electro- 
cautery, but has employed the chromic-acid and silver-nitrate beads 
with satisfactory results. 

(Edema of the Laryxx. 

Synonyms. — (Edematous laryngitis; purulent laryngitis; oedema 
glottidis. 

Pathology. — The loose attachment of the mucous membrane to 
the walls of the larynx favors infiltration and separation of the mu- 
cosa from the cartilages (Plate VI). The changes that take place in 
acute cedematous inflammation occur so rapidly as to preclude their 
study, the disease proving rapidly fatal in many cases. In this form 
the infiltration consists of serum, but in the more protracted attacks 
it consists of a mixture of serum and pus, with effusion of blood in 
occasional instances. The epiglottis is sometimes involved to the 
extent of becoming greatly enlarged. The loose areolar tissue of the 
aryepigl6ttic folds is probably more copiously engorged with the fluid 
exudate than any other portion of the larynx, and the ventricular 
bands suffer nearly as much. The true vocal bands may escape alto- 
gether or participate to the degree of slight swelling. The laryngeal 
muscles may present a water-soaked appearance, if a post-mortem ex- 
amination is made, after death due to this disease. Associated with 
oedema of the larynx may lie a similar infiltration o( the pharynx ami 
even of the neck. 



CEDE}! A OF THE LARYNX. 293 

Etiology. — Most cases of laryngeal oedema occur between the 
ages of 20 and 35 years, and are nearly three times as frequent in men 
as in women. It may be idiopathic or symptomatic. Nearly three 
times as many cases are secondary as are primary in character, — that 
is, most cases are consecutive to some other affection, such as Bright's 
disease, that gives rise to a dropsical condition of lax tissues. When 
oedema of the phar} r nx invades the adjacent laryngeal tissues, the 
latter is termed contiguous oedema; and when laryngeal oedema is 
secondary to some other disease of the larynx it is designated as con- 
secutive. Any cause that operates to produce inflammation of the 
laryngeal mucosa or submucosa may be a cause of oedema. Exposure 
to cold or impure air containing irritating particles or gases, injuries, 
scalds, corroding chemicals, and certain diseases, such as Bright's 
disease, syphilis, tuberculosis, and typhoid and the eruptive fevers 
cause or predispose to this disease. 

Symptomatology. — The prominent and most distressing symptom 
is the difficulty of respiration. There is a sensation as if a foreign 
body had gained entrance into the throat, and difficulty of swallowing 
adds to the suffering. As the swelling and consequent stenosis of the 
larynx progresses, the labor of breathing becomes more arduous, until 
the patient is threatened with impending suffocation. As the lumen 
of the larynx is encroached upon, and the pressure of the tumefied 
tissues increases, the voice becomes feeble and finally disappears. 

Frequent efforts are made to clear the throat of the obstruction, 
but they are not of the character of a cough. There is but little 
expectoration, and this consists of mucus. The suffering occasioned 
by this disease is intense, not only of the patient, but of his helpless 
friends. He cannot lie down, but sits with his body and head thrown 
forward, unable to speak, but exerting every muscle to draw in enough 
air to support life. He calls to the bystanders for help, has them 
support his arms and shoulders, one attendant on either side, while 
he seeks the open window for air. The noise of inspiration is harsh 
and indicative of the extreme narrowing of the glottis. Moments 
of relaxation and relief may occur, only to be followed by the par- 
oxysm that threatens immediate suffocation. As the sufferer gasps 
for air, with open mouth and horror-stricken eyes, his face puffed and 
purple, his whole frame convulsed with an agonizing struggle for life, 
the surgeon or death soon comes to his relief and closes the scene. 

Inspection, when it is possible, reveals the epiglottis red and 
swollen to enormous proportions, and it may cut off a view of the 



294 (EDEMA OF THE LARYNX. 

laryngeal cavity. The enlargement becomes so excessive as to amount- 
to a deformity. The aryepiglottic folds are seen to be tumefied even 
to the point of medial contact with each other over the laryngeal 
opening during inspiration. 

When inspection is impossible, a quick, but gentle, palpation 
with the finger, not interrupting respiration to a dangerous degree, 
may enlighten the examiner as to the condition present. The roll- 
like character of the epiglottis and the spongy feeling of the aryepi- 
glottic folds are characteristic. 

Diagnosis. — (Edema of the larynx may be mistaken for the pres- 
ence of a foreign body, polypus, retropharyngeal abscess (Plate IV), 
acute laryngitis (Plate VI), or pulmonary emphysema. The symp- 
toms and the conditions presented on examination are sufficient to 
mark the differences. Diphtheria of the larynx can be detected by 
the discharge of shreds of the false membrane, and the latter is gen- 
erally found in the pharynx also. 

Prognosis. — About one-half of all cases of this disease terminate 
fatally. Acute laryngeal oedema has an average duration of about a 
week. Cases arising in the course of pharyngeal oedema generally 
pursue a favorable course, but those resulting from aneurism of the 
aorta or of other important vessels of the neck prove fatal. The 
same is true of oedema arising from an extension of the disease from 
the external areolar tissue. Tubercular oedema is unfavorable, but 
the syphilitic type is amenable to treatment. The prognosis should 
always be guarded. 

Treatment. — Scarification is the classic remedy, but there are 
other means of relief that have come into use in later years. Pilocar- 
pine depletes the blood-vessels of their serum and is indicated here 
to drain the water-soaked tissues. It can be given in doses of y s or 
Vie grain until free salivation and diaphoresis are produced. Enough 
to cause heart-depression should not be administered. 

In violent acute cases the blanching, shrinking, and anaesthetic 
effects of cocaine would appear to be indicated. 1 have never tried it 
in this condition, nor have I seen it mentioned in this connection, 
but for prompt action and immediate relief from impending suffoca- 
tion its physiological action suggests it- use. The action o{ suprarenal 
extract in contracting the blood-vessels and shrinking the tissues 
promises well. Unless a speedy change for tlie better takes place, 
scarification, intubation, or tracheotomy should be done. 



(EDEMA OF THE LARYNX. 



295 



When oedema has become chronic, its treatment is much like 
that of chronic laryngitis, with the addition of scarification. Dilata- 
tion by Schrotter's method with hard-rubber tubes has proved useful, 
and the intubation-tubes promise good results. In severe cases 
tracheotomy may become imperative. 



CHAPTER XXV. 

DISEASES OF THE LARYNX (Continued). 

Neukoses. 

spasmodic croup. 

Synonyms. — Spasm of the larynx; spasm of the glottis; laryn- 
gismus stridulus. 

Pathology. — According to Marshall Hall, this is a reflex nervous 
disease the exciting cause of which may be located in remote organs, 
— for example, in the teeth, the intestinal tract, or at a point of 
pressure on the recurrent laryngeal nerve. It is believed by some 
authorities to be of purely cerebral origin. 

Etiology. — This is, for the most part, a disease of childhood, 
although it occasionally occurs in adult life. It may be brought on 
by the accidental entrance of liquid or food or any foreign body 
into the larynx. Dentition is a common cause, and mental emotion 
may give rise to attacks. 

Symptomatology. — The closure of the glottis may be complete 
or incomplete. In the former case there is entire arrest of respiration 
temporarily. The child is taken with a sudden convulsion; the eyes 
are rolled; the hands and feet are cramped, and even opisthotonos 
may supervene. All at once a spasmodic inspiratory movement oc- 
curs, announcing the cessation of the spasm. When the glottis is 
incompletely closed, the air passes through it with a harsh, croupy 
sound, which resembles closely a crowing of croup or the whoop of 
whooping-cough. During these distressing attacks the face becomes 
flushed, congested, or livid, according to the severity of the attack, 
and the veins of the neck are distended. In extreme cases the spasm 
does not relax and the child dies in convulsions. 

These attacks may follow each other rapidly, or one only may 
occur at long intervals, and the child appears in excellent health be- 
tween the attacks. They occur usually at night, waking the child out 
of a sound sleep. They are not accompanied by fever or cough, but 
there is copious perspiration. Children under 2 years of age are most 
(296) 



ANOMALIES OF SENSATION". 297 

frequently subject to this disease, and boys are attacked more often 
than girls. Those whose systems are impoverished are the most likely 
to suffer. In this respect spasmodic croup differs from true croup. 

Diagnosis. — Spasmodic croup does not closely resemble any other 
disease except true croup, from which it can be differentiated by the 
absence of fever and false membrane and by the presence of good 
health as soon as the transitor}- paroxysm yields and normal respira- 
tion succeeds. 

Prognosis. — When the attacks do not show a high degree of in- 
tensity of the spasmodic contraction, and when they do not last long 
or do not occur at short intervals, the prognosis is usually favorable. 
But when the closure of the glottis is complete the child may die of 
strangulation before help can be summoned. The more frequently 
the paroxysms occur, the more danger there is to life. If the spasms 
are due to cerebral disease the prognosis is grave. 

Treatment. — For immediate relief a few drops of amyl-nitrite, 
ethyl-bromide, chloroform, or ether may be inhaled, if any air is 
inspired. If not, dashing cold water in the face, slapping the back 
of the shoulders, applying ice to the back of the neck, tickling the 
throat, or introducing the finger to cause vomiting may succeed in 
aborting the attack. While the finger is in the throat it should be 
used to learn whether the epiglottis is impacted in the aperture of 
the larynx, and, if it is, the tip of the finger should be hooked under 
the epiglottis and made to raise it into position. Drawing the tongue 
out of the mouth also raises the epiglottis. A hot mustard bath may 
relax the spasm. Hypodermic injections of apomorphine, in very 
minute doses, or a dose of turpeth mineral, 1 or 2 grains, may excite 
vomiting and end the paroxysm. Powdered alum in teaspoonful 
doses is a harmless and efficient emetic. 

The cause of the attacks must be ascertained and prophylactic 
measures adopted. Laryngitis, indigestion, troublesome teeth, or 
irritation of the genital organs, especially of the prepuce, may bear 
a causative relation to this disease. As a rule, general tonics, nervous 
sedatives, and an especially nutritious diet are indicated. 

ANOMALIES OF SENSATION. 

Hyperesthesia, neuralgia, and paresthesia of the larynx are 
most commonly met with in singers and public speakers who strain 
their vocal organs. 



298 ANOMALIES OF SENSATION. 

Pathology. — Congestion of the laryngeal mucous membrane is 
often present, but inspection may not reveal any apparent structural 
change; this is true when the affection is purely neurotic. 

Etiology. — Excessive use of the voice after faulty methods, over- 
indulgence in alcoholic beverages, excessive smoking, varicose veins 
and hypertrophied glands at the base of the tongue and inflamma- 
tory affections of the larynx occasion hyperesthesia. The causes of 
paresthesia are quite numerous and sometimes obscure. Anything 
that produces a depressed condition of the nervous system may be 
said to predispose to this nervous anomaly. Foreign bodies in the 
larynx and inflammatory conditions of the mucous membrane cause 
it. To these causes, and to the uric-acid diathesis, neuralgia is due. 

Symptomatology. — The laryngeal mucous membrane is often ex- 
quisitely sensitive in hyperesthesia, so that dusty or cold air, the 
fumes of a match, smoke, etc., provoke fits of coughing. There is 
usually a sensation of dryness, or scratching, or tickling in the larynx 
that excites hemming or slight coughing to give relief. Neuralgia 
here, as elsewhere, is not constant. Fugitive pains and sensations of 
soreness of a transitory nature are present. In paresthesia there are 
unusual sensations, generally of a foreign body in the larynx. Pa- 
tients sometimes can scarcely be convinced that the impression is 
not produced by a foreign substance. This is called globus hystericus. 

Diagnosis. — There is not much difficulty in deciding upon the 
nervous nature of these affections, since examination generally fails 
to discover any physical signs. The symptoms are quite character- 
istic. 

Prognosis. — These troubles are rather annoying than serious. 
They are persistent, but amenable to treatment. 

Treatment. — If any irritation is found, the throat-tablets — con- 
taining ammonium chloride, 1 grain; camphorated tincture of opium, 
compound syrup of squills, and syrup of Tolu, each 5 minims; and 
extract of licorice, 3 grains — may allay the irritation and cough. In- 
halations of oil of cubebs, carbolic acid, salol, and eucalyptus in lavo- 
lin, as described under the healing of "Sprays and Inhalents," are 
beneficial. When hypertrophied glands and varicose veins are found 
in the pharynx, and especially about the base of the tongue, they 
are to be eradicated by means of the- cautery. The bromides and 
other nervous sedatives and nervous stimulants, like valerianate of 
ammonia, are demanded in certain cases. General tonic treatment is 
often necessary, combined with a fattening regimen. 



NERVOUS APHOXIA. 299 

TT. Peyre Porcher emphasizes the fact that the lithic-acid di- 
athesis ma}- stand in a causative relation to these neuroses, and that 
such cases must receive antirheumatic treatment, including colchi- 
cum, salol, guaiac, the salicylates, etc. 

XERVOUS APHOXIA. 

Synonyms. — Hysterical aphonia; hysterical paralysis of the vocal 
cords; functional aphonia. 

Pathology. — This is a functional bilateral paresis of the lateral 
cricoarytenoid muscles, interfering with the normal relations of the 
vocal cords during attempted phonation. They cannot be properly 
approximated. It is not due to any organic lesion, but to a temporary 
loss of the power of muscular co-ordination or of innervation. 

Etiology. — This affection is a symptom of hysteria and debili- 
tating diseases. It occurs most frequently in unmarried women, and 
is especially marked between puberty and the establishment of the 
menopause. 

Symptomatology. — A peculiarity of this disease is that the pa- 
tient may not be able to utter the common conversational tone, but 
may cough or laugh audibly, which does not occur in complete paraly- 
sis. The onset is sudden, like that of spasmodic croup, and the pa- 
tient cannot attribute it to any cause; or it may follow upon an 
intense mental impression. Even whispering is sometimes out of the 
question. The attacks are irregular, appearing one day and disap- 
pearing the next, without any premonitoty signs or symptoms. The 
impression of cold often develops the symptoms, and this fact may 
account for patients, exposed to draughts of air at night, losing their 
voices between the hours of retiring and arising. 

Inspection during phonation shows the effect of the loss of power 
of the adductors. The vocal cords cannot be brought into close re- 
lationship. Efforts to approximate them may cause a spasmodic ap- 
proaching of the cords, followed immediately by their wide separation. 
Unless a catarrhal condition exists, the larynx is pale and presents no 
inflammatory appearances. 

Diagnosis. — The history, symptoms, and appearances described 
render the diagnosis easy. 

Prognosis. — This is favorable, although there is a liability of 
the attacks to return. This is the kind of trouble in which the various 
sorts of "mind-cures" are effective. The mental impression made by 



300 REFLEX AFFECTIOXS OF THE VOICE. 

simply introducing an} T indifferent instrument, such as a laryngeal 
mirror, into the throat may restore the voice. In other cases actual 
treatment must be pursued for a considerable time to effect a cure. 

Treatment. — Strychnine, beginning with 1 / 30 grain and increased 
gradually until its physiological effects are produced, and electricity 
are efficient remedies. Sir Morell Mackenzie devised a laryngeal elec- 
trode for this purpose, by means of which one electrode is applied 
within and the other without the larynx. The galvano-faradic cur- 
rent is preferable. If the muscles have not become atrophied this 
treatment is speedily beneficial. 

The elixir of the valerianate of ammonia, combined with quinine, 
if a tonic effect is desired in addition to that of a diffusive nervous 
stimulant, meets the indication admirably. Zinc valerianate in 1-grain 
doses every four hours is recommended by Sajous, as well as coca-wine. 

EEFLEX AFFECTIOXS OF THE VOICE. 

The condition of the vocal cords is affected by certain states of 
the generative organs. Singularly enough, the same causes seem to 
produce opposite effects in different subjects. The author has ob- 
served that in some soprano singers the occurrence of the menses is 
accompanied by a huskiness, or roughness of timbre, of the voice; 
but in others the same periods are characterized by a clearer, fuller, 
and more flute-like quality of tone. However, the latter effect is 
probably exceptional. Uterine and ovarian diseases have a deleterious 
effect on the voice, especially noticeable in the singing voice, and any 
treatment to restore the voice-deterioration must include gynaecolog- 
ical measures. C. II. Leonard has reported cases in which voices 
impaired by uterine disease have been restored, and in one case two 
full notes were said to have been added to the upper register of a high 
mezzosoprano as a result of uterine treatment. In the latter case 
there were anteflexion, narrowing of the uterine canal, and endome- 
tritis. > 

These facts are not surprising when we consider the close sym- 
pathetic relations existing between the uterus and the central nervous 
system. Bischoff has shown that division of the spinal accessory 
nerve, or of the inferior laryngeal, causes aphonia. The close rela- 
tionship of the nervous supply of the sexual organs in the male to the 
innervation of the larynx is aptly illustrated' in the unnatural voices 
of the castrated male sopranos. The voices of hermaphrodites, also, 
are anomalous. 



LARYNGEAL PARALYSIS. .301 



LARYNGEAL PARALYSIS. 

The laryngeal muscles may be paralyzed singly or in pairs, or 
several muscles may be affected simultaneously. The paralysis may 
be unilateral (Plate VII) or bilateral, affecting only one side or both. 
Anaesthesia of the laryngeal mucous membrane may exist as a compli- 
cation. The paralysis may be of central origin, the disease being 
located in that part of the brain in which the laryngeal nerves have 
their origin, or it may be due to a disease in the course of the nerve- 
trunk. On the other hand, the lesion may be of a local character, the 
muscles being affected either primarily or secondarily to some de- 
bilitating systemic malady. 

Pathology. — Cerebral causes of paralysis of the laryngeal mus- 
cles are: the gummata of syphilis, apoplexy, multiple sclerosis, 
tumors, etc. Diphtheria is one of the most frequent causes, aneurisms 
and tumors in the neck, progressive bulbar paralysis, hypertrophied 
glands, etc., are among the causes. The recurrent laryngeal nerve is 
subject to pressure from aneurism of the arch of the aorta, the left 
carotid, or the subclavian artery. Aneurism of the carotid, the sub- 
clavian, or the innominate artery on the right side may produce the 
same effect. These conditions result in unilateral paralysis, in which 
the epiglottis cannot be completely closed and there is loss of power 
to extend the vocal cord. When an aneurism or other tumor is large 
enough to occasion pressure on both recurrent laryngeal nerves bilat- 
eral paralysis results. 

The laryngeal muscles may become the seat of disease which, 
independently of any affection of the nerves, may impair or destroy 
their function. An extension of the inflammatory action from the 
mucous surfaces to the muscular tissue, with exudation and swelling, 
may produce a paretic condition of a transitory nature. Degenera- 
tive changes, such as atrophy of the muscular tissues, may occur to 
such an extent as to eventuate in muscular paralysis. 

Etiology. — Certain drugs and chemicals cause laryngeal motor 
paralysis, such as the following: Belladonna, opium, phosphorus, ar- 
senic, mercury, lead, and alcohol. Such diseases as diphtheria, rheu- 
matism, syphilis, anaemia, and inflammation of the adjacent areolar 
tissue and glands are causative conditions. 

When paralysis of the muscles of abduction — the posterior 
cricoarytenoid — occurs, the vocal cords lie in such constantly close 
relation to each other as to present a serious obstruction to respira- 



302 . LARYNGEAL PARALYSIS. 

tion. The breathing is noisy and labored, and suffocation is immi- 
nent. The voice is not affected because of the action of the aryte- 
noidens muscle in approximating the vocal bands. When unilateral 
paralysis of the posterior cricoarytenoid muscle takes place there is 
no dyspnoea except on great exertion (Plate VII). When both sides 
are affected it may be due to brain disease in the region of the fourth 
ventricle or in the medulla affecting the pneumogastric and spinal 
accessory nerves. 

Paralysis of the muscles of adduction — the lateral cricoarytenoid 
— results in the vocal cords remaining in a condition of abduction, or 
separation from each other as far as possible. This occurs most fre- 
quently in hysteria and leaves no vestige of the voice. If this pa- 
ralysis is unilateral, whispering may be possible. 

When paralysis of the arytenoideus muscle happens the voice is 
very feeble or altogether lost. A triangular space between the vocal 
cords, behind the vocal processes, remains during phonation in conse- 
quence of the loss of contractility of this muscle. 

Paralysis of the muscles of tension — the thyrocricoid and the 
thyro-arytenoid muscles — is not infrequent. Paralysis of the thyro- 
cricoid muscles leaves the vocal cords relaxed and uneven. They 
may be seen in contact with each other at irregular intervals and 
moving unnaturally, — depressed and elevated in the currents of air. 
The timbre of the voice is changed to a hoarse, monotonous quality. 
The respiration may be more or less embarrassed. Paralysis of the 
thyro-arytenoid muscles prevents approximation of the vocal bands, 
especially at their centres, so that an elliptical aperture remains be- 
tween them. The voice is feeble, easily wearied, high-pitched, and 
husky. Inordinate use of the voice is the most frequent cause of this 
form of paralysis. 

All three forms of paralysis already described sometimes co-exist, 
— paralysis of abduction, adduction, and relaxation. This condition 
results in total suppression of the voice. The vocal bands remain 
passively half-way between abduction and adduction, or in the ca- 
daveric position. The usual causes are aneurism of the arch of the 
aorta, goitre, or disease of the oesophagus. If a brain disease were 
the cause, there would be loss of sensation and an erect epiglottis, 
indicative of paralysis of the superior laryngeal nerve. There may 
be unilateral paralysis of abduction, adduction, and relaxation, in 
which case but one vocal band assumes the cadaveric position (Plate 
VII). In this form of paralysis the opposite and unall'ected vocal 



LARYNGEAL PAEALYSIS. 303 

cord may perform vicarious function, so that the voice is but little 
roughened in quality; but, unless the power exists to draw the healthy 
cord beyond the median line to approximate its paralyzed fellow, the 
voice is seriously affected or destroyed. The effort of speaking soon 
tires the patient, and exertion causes labored respiration. 

Treatment. — The wide variation in the nature of the causes of 
laryngeal paralysis renders it impracticable, in a work of such an 
elementary character as this, to deal in detail with all of them. Le- 
sions of the nervous centres, of the circulatory system, of the apex 
of the lungs (especially of the right, a disease of which may cause 
pressure on the recurrent laryngeal nerve), enlargement of the glands 
of the neck, inflammation of the surrounding tissues and of the laryn- 
geal mucous membrane, tumors, and rheumatic and syphilitic con- 
ditions call for treatment adapted to each disease. Drug and chem- 
ical poisoning must be met with antidotes, restorative measures, and 
removal of the cause. 

Strychnia, internally and hypodermically, to the degree of pro- 
ducing its physiological effects, is valuable. The faradic current, ap- 
plied to the interior and exterior of the larynx by the special laryn- 
geal electrode, is efficacious. If the mucous membrane of the larynx 
is sensitive it may have to be cocainized to admit of the application 
of the negative pole to the interior of the cavity. The current is 
applied by means of the kid-covered electrode, the tip of which must 
be moistened. By the aid of the laryngeal mirror this electrode is 
carried to the points that require the current, while the positive pole 
is applied to the front or sides of the exterior of the larynx. Com- 
pound electrodes are made so that both poles may be applied within 
the larynx. Their use is attended with more difficulty than presents 
in the introduction of the single electrode. The current is turned 
on for a few seconds at a time, and repeated frequently during a 
treatment, which is given on alternate days. General tonic treat- 
ment and appropriate hygienic measures must be employed, according 
to the necessities of each case. 



CHAPTEE XXVI. 
DISEASES OF THE LARYNX (Continued). 

Tuberculosis of the Larynx. 

This is one of the most common of laryngeal affections and gen- 
erally proves fatal. It is seldom a primary disease, but usually is 
associated with the same condition in other organs, and in such cases 
is a secondary affection. About 25 or 30 per cent, of cases of pul- 
monar}^ tuberculosis exhibit laryngeal invasion. 

Pathology. — The pathogenic principle of tuberculosis consists 
in a micro-organism, — the tubercle bacillus, — which gains entrance 
into the laryngeal tissues by becoming ingrafted upon an area of 
mucous membrane denuded of its epithelium. Within a few weeks 
after the development of primary laryngeal tuberculosis the lungs are 
invaded by the infection; so that we witness an intimate reciprocal 
relation between the various sections of the air-passages: laryngeal 
tuberculosis is very often a sequel of pulmonary tuberculosis, and 
consumption of the lungs may develop as a secondary manifestation 
of tubercular infection of the larynx. 

Generally the first changes observable in the larynx are: an un- 
natural paleness and tumefaction of the epiglottis (Plate VI), suc- 
ceeded by a superficial, ragged-edged ulceration on the posterior sur- 
face of the epiglottis, as seen in the mirror. Multiple ulcers soon 
form in other parts of the respiratory tract, extending below to in- 
volve the trachea, on the one hand, and upward into the pharynx, on 
the other. The ulcerative process may destroy the epiglottis. 

In acute tuberculosis of the larynx the development and course 
of the disease are often so rapid as to result fatally in the space of 
only a few weeks. This is known as miliary tuberculosis. These 
areas of miliary tubercle are easily made to bleed by pressing upon 
them. The mucosa and submucosa become infiltrated, sometimes in- 
volving the mucous glands, and, as the disease advances, caseous de- 
generation occurs in the tubercles -au^ adjacent tissues. In the acute 
form the membrane is seen to be congested, instead of pale, as is 
characteristic of the chronic form. 
(304) 



TUBERCULOSIS OF THE LARYNX. 305 

A peculiarity of this disease is that it may stop short at the vocal 
cords, in its downward course from the pharynx and through the 
larynx, and leave the cords unaffected, although the ventricular bands 
are involved even to the extent of so great tumefaction as to com- 
pletely hide the vocal cords. Sometimes, however, the latter become 
thickened to such a degree as to threaten suffocation. The processes 
of infiltration, caseation of the tubercles, fatty degeneration of the 
mucous glands, and breaking down and melting away of the mucous 
membrane over these tubercular areas proceed until the whole of the 
interior of the larynx may become involved. The destruction con- 
tinues until the cartilage itself becomes ulcerated, necrosed, and dis- 
integrated. As seen in Plate VI, the cartilages are thickened until 
the indentations separating the cartilages of Santorini and Wrisberg 
are obliterated. The resulting tumefaction appears in the shape of 
a pear. 

Etiology. — Tuberculosis of the larynx is usually consequent upon 
a pre-existing pulmonary consumption, although a primary lesion 
may occur in the larynx, as a result of the reception of the tubercle 
bacillus at a point on the mucous membrane where desquamation of 
the epithelium has occurred. Catarrhal affections, exposure to cold 
and wet and to an irritating atmosphere are predisposing causes. In 
pulmonary phthisis the lodgment of the tuberculous sputa from the 
lungs, as must occur in the larynx during expectoration, naturally 
tends to produce secondary points of inoculation. 

Heredity is not emphasized as strongly as it was in former years, 
but inherited tendencies and weakness and a positive predisposition 
to tuberculosis cannot be denied, in the light of actual clinical experi- 
ence. 

Symptomatology. — The visible pathological conditions already 
detailed need not be repeated. The sensations of the patient are very 
positive in their character. Pain is often a conspicuous symptom, 
especially during the act of swallowing. The voice shows early the 
presence of a laryngeal trouble, and the hoarseness and feebleness 
may progress until no sound can be uttered. 

When the posterior surface of the larynx is ulcerated the pain 
produced by swallowing may be excruciating. Sometimes the pain 
reaches to the ears, indicating ulceration of the pharyngo-epiglottic 
folds. 

Difficult respiration is not a common symptom, but may result 
from great swelling of the vocal cords, abscesses, or the presence of 

20 



306 TUBERCULOSIS OF THE LARYNX. 

detached pieces of necrotic cartilages or of tumors. One of the most 
common features of this disease is cough. Patients complain of sen- 
sations of irritation, at first described as a tickling in the throat or 
larynx. At this early stage the cough is of a hacking character and 
without expectoration. When ulceration takes place or abscesses 
form, or when pulmonary tuberculosis is progressing, the cough is 
attended with expectoration. 

Diagnosis. — Generally an examination of the lungs will reveal 
the seat of the primary source of infection. As laryngeal tubercu- 
losis may be associated with the same disease of the pharynx, in- 
spection of the latter may disclose the nature of the malady. The 
laryngoscopic examination may bring to light the patches of miliary 
tubercle, but these tubercles cannot always be distinguished from 
hypertrophied racemose glands. 

In the early stages this disease is likely to be confounded with 
simple catarrh, but, as the latter yields readily to treatment and 
presents no symptoms of gravity parallel with those of localized or 
general tuberculosis, in view of the history of the case, habit of body, 
probable involvement of the lungs, joints, or other structures, and 
the laryngeal appearances, one should scarcely err. 

Prognosis. — Occasionally a case recovers; nearly all die. Acute 
tuberculosis of the larynx kills in a few weeks or months. In the 
secondary laryngeal tuberculosis consecutive to pulmonary consump- 
tion and characterized by caseation with acute symptoms, the disease 
proves fatal in from six to eighteen months. These cases may pursue 
a more chronic course and last from two to four years or longer. It is 
a difficult matter to cause a tuberculous ulcer to heal, and, if it does, 
it usually breaks out again. 

From 10 to 40 per cent, of all patients with pulmonary tuber- 
culosis have this laryngeal complication, which shortens the duration 
of life. 

Treatment. — The treatment given in detail for tuberculosis of 
the pharynx is just as applicable here, and to avoid unnecessary repe- 
tition the reader is referred to that article for those remedies that 
are not given here. 

Lennox Browne (Journal of Laryngology, etc.) maintains that 
curettemenf is noi absolutely necessary in this disease. Menthol, or 
menthol with iodol, in spray is besl in the pre-ulcerative stage. For 
pain he uses the ethereal solution o\ aristo] in a spray. Morphia in- 
sufflations are n>c<l in hopeless cases only, buj codeia largely, and 



TUBERCULOSIS OF THE LARYNX. 307 

cocaine before manipulations and in advanced dysphagia. Spra}*s are 
better than insufflations of powders. Excepting for relief of acute dys- 
phagia, he prefers applications of the tincture-of-benzoin compound, 
tincture-of-camphor compound, and tincture of belladonna mixed 
with yelk of egg just before food. He employs lactic acid rubbed in 
with considerable force, but not employed previously to ulceration. 
The lactic acid is useless unless preceded by curettement once to 
about every four or six applications of the acid. He curettes for the 
removal of hyperplasia and to clear away the necrotic matter when 
the ulcers are large, and for converting all the ulcers into one. 

J. Price-Brown relies largely on sprays in the early history of this 
disease. He says: "Of all the medicaments that can be applied in 
this manner, I have found none so useful as different percentages of 
menthol in albolene." He uses solutions varying in strength from 
2 to 10 or 20 per cent. 

Desire recommends exalgin twice a day in doses of 4 grains as 
effective in relieving the difficulty of swallowing and pain. Wolf enden 
recommends feeding the patient while lying on his stomach while 
his head depends over the end of the couch, which is elevated so as 
to bring his feet higher than his head. He then takes liquid nour- 
ishment through a tube from the dish placed below his head. 

The anti tubercular serum of Paul Paquin has been used in a 
considerable number of cases of tuberculosis with benefit. I have 
been able to gather together reports from 369 cases that are of value, 
besides a large number that have been reported with such a degree 
of inexactness and indefiniteness that in giving the results it is neces- 
sary to eliminate them from the records. These ambiguous state- 
ments appear even more reassuring than the carefully prepared ones. 
Paquin has reported 293 cases, with the following results: Eecoveries 
that seem permanent, 57; considerably improved, 38; improved, 121; 
disappeared from observation, 41; deaths, 36. I have reports of 
76 cases to add to the above, giving the total results as follow: Ee- 
coveries, 71; improved, 205; unimproved, 14; disappeared, 41; 
deaths, 38. 

Similar results from an oxygenated serum have been reported 
from San Francisco, but it is too early to speak judiciously regarding 
them. 

Since the beginning of the year 1898 unfavorable reports from 
the use of Koch's tuberculin both in tuberculosis and lupus of the 
throat and nose have emanated from Munich, Hamburg, and Prague, 



3.08 SYPHILIS OF THE LARYNX. 

although some improvement, rather than any cure, was recorded in 
the Berlin clinics. 

When abscesses, growths, etc., produce so great obstruction to 
respiration as to threaten suffocation, tracheotomy must be done as 
a last resort. 

Syphilis of the Larynx. 

Pathology. — Syphilis of the larynx belongs almost always to the 
secondary or tertiary stage. It is first manifested by the appearance 
of a deep blush of congestion of the laryngeal mucous membrane, 
characterized by dryness. A little later the mucosa becomes swollen 
by serous infiltration, and this stage is soon followed by shallow, 
ulcerating patches (Plate VII). The changes that take place in the 
larynx are similar to those occurring in the pharynx, but the results 
may be far more serious, owing to the diminished calibre of the larynx, 
which renders tumefaction and cicatricial contraction grave affairs. 
Mucous patches are likely to be found associated with the same 
lesions of the pharynx, and occur from three weeks to about three 
months or longer, following the initial sore. They are not found 
below the vocal cords, where there are no papilla?. When the papilla? 
are attacked they appear as small, red excrescences, swelling to the 
calibre of a small pea and obstructing respiration. From a rosy-red 
color they change to an ashy gray surrounded by a zone of red. They 
may disappear by the process of absorption or ulceration. A sudden 
infiltration of the mucous and submucous tissues is an occasional oc- 
currence, and in this situation is of serious import, since the resulting 
oedema may impede respiration to the point of strangulation. 

The tertiary stage is characterized by the presence of gummata, 
which become the seat of ulceration. When the erosions penetrate 
deeply into the submucosa the invasion of the blood-vessels gives rise 
to hsemorrhages. Following these deep ulcerations are found white, 
corrugated, contracting cicatrices that lessen the lumen of the cavity 
by their contractions. Adhesions of adjoining denuded tissues pro- 
duce the same effect sometimes in a very short space of time. In 
this manner gross and obstructive deformities of the epiglottis, ven- 
tricular bands, and vocal cords give rise to a dangerous stenosis of the 
larynx. 

In the later stages of tertiary syphilis the laryngeal muscles and 
cartilages are invaded, with the result of producing paralysis, as well 
as ankylosis and destruction of the cartilages. 



SYPHILIS OF THE LARYNX. 309 

Etiology. — Syphilis of the larynx is most often a tertiary lesion, 
occurring from three years to a much longer period after the initial 
ulcer. If it exist as a secondary manifestation, it follows the primary 
infection in a few weeks or months, the margin of the incubatory 
period in syphilis being very broad. These syphilitic invasions of 
the larynx are very rarely primary, and they are more frequent in 
men than in women. 

Symptomatology. — As will be seen from the description of the 
pathological appearances in laryngoscopy, the first stage of syphilitic 
laryngitis closely resembles acute laryngitis of the simple variety. It 
may be impossible to distinguish early between the two unless a spe- 
cific history can be obtained. But in the syphilitic form of congestion 
or inflammation the rosy hue of the mucous membrane assumes a 
comparatively mottled arrangement, which is quite characteristic of 
this affection. These patches of redness are likely to be elevated 
above the surrounding surface and to show early evidences of be- 
ginning erosions of a superficial kind. In this period sensations of 
soreness, difficulty of swallowing, and pain appear. The voice begins 
to change in quality; the pitch is lowered, and a coarse timbre is 
imparted to it. A slight cough makes its appearance, occasioning 
little inconvenience, and accompanied by a muco-purulent expecto- 
ration. 

Inspection reveals the picture already described, resembling a 
simple laryngitis. The vocal cords may be involved sufficiently to 
show a congested condition (Plate VII), which may be bilateral when 
one side of the larynx is involved to a greater extent than the other. 
Mucous patches are most frequently found on the epiglottis, in the 
interarytenoid space, and on the ventricular bands. They do not 
differ in appearances from those described as occurring in the phar- 
ynx. Papiilomata are occasionally present, and can be seen as little, 
wart-like excrescences, or they may assume the appearance of yellow- 
ish pimples, nearly as large as a small pea. The mucous patches may 
disappear in a couple of weeks, when subjected to treatment, and 
leave a blushing area that gradually fades from sight. The condylo- 
mata may become absorbed or may ulcerate away. 

In the tertiary stage the epiglottis is most likely to be first in- 
vaded by the destructive process, ulcerations generally breaking out 
on the surface next to the tongue or on its border. From this region 
they spread to the laryngeal cavity, differing from the erosions of 
the secondary stage in their invasion of the deeper layers of the mu- 






310 . SYPHILIS OF THE LARYNX. 

eons membrane, in the roughened surfaces cine to granulation forma- 
tion, or to papillomata. The ulcers of the secondary stage are super- 
ficial patches; the ulcers of the tertiary period are deep-seated and 
destructive. 

Symmetrical bilateral lesions are characteristic of syphilis. When 
an ulcer forms on one side of the larynx one may confidently expect 
soon to find its fellow situated in a corresponding area of the opposite 
side. The irregular, ulcerating surfaces are surrounded by a dark- 
red zone, and are bathed in a purulent discharge, which is expec- 
torated in abundance and imparts a foul stench to the breath. The 
cartilages break down and are thrown off in the expectoration. The 
epiglottis may disappear, and the particles of necrosed walls of the 
larynx may drop down into the chink of the glottis and threaten 
suffocation. When the deep erosions attack the walls of the blood- 
vessels and destroy their coats, serious haemorrhages may take place. 

Deformities due to swellings, cicatricial contractions, expulsion 
of parts of the cartilages, and muscular paralysis occur in the ter- 
tiary stage. Stenosis and consequent embarrassment of the respira- 
tion may then endanger life. 

Diagnosis. — This disease may be mistaken for tuberculosis, and 
in the early stage may be confounded with a simple catarrhal inflam- 
mation of the mucous membrane; but the latter yields readily to 
treatment, while the syphilitic disease progresses uninfluenced by any 
other than specific treatment. 

In tuberculosis serious constitutional disturbances are present, 
such as are not accompaniments of syphilis: fever, emaciation, etc. 
The areas of hyperemia that later become the seat of ulceration arc 
paler and softer in tuberculosis than in syphilis. The ulcers of syphi- 
lis have more regular, clearly defined borders, and are deeper than 
in tuberculosis. The pain of the latter disease, especially in swallow- 
ing, causes great suffering, while it is not a prominent symptom of 
syphilis' and may be absent altogether. The patient improves and 
gains in weight on specific treatment in syphilis, but grows worse in 
tuberculosis. The presence of pulmonary tubercular lesions will aid 
in clearing up the diagnosis. 

Prognosis. — This disease yields most brilliant results except in 
extreme cases of the tertiary type, in which great deformities and loss 
of structure and function occur. 

Treatment. — Constitutional remedies alone will often dissipate 
laryngeal syphilitic lesions without the introduction of local treat- 
ment. This disease, therefore, requires less mechanical skill in its 



SYPHILIS OF THE LARYXX. 311 

management than tuberculosis and other affections of the larynx. 
In the early stages mercurials are indicated, while in the later periods 
the iodides are called for, or the mixture of the two, which is often 
more efficacious than the iodides alone. 

The use of the voice, alcoholic stimulants, and tobacco must be 
interdicted, and in the secondary manifestation 1 / 16 grain, or even 
more, of the bichloride of mercury may be given thrice daily. If the 
green iodide is employed, V 6 grain may be used. Inunctions of mer- 
curial ointment may be resorted to if the stomach reject internal 
treatment, a drachm being rubbed into the skin. In ulcerations a 
spray of carbolic acid and iodine in lavolin, 4-per-cent. solution, is 
useful when thrown into the larynx so as to bathe the ulcerated sur- 
faces. This has mildly anaesthetic and alterative effects and answers 
the purpose of a detergent and protective. 

In the tertiary stage the mixed treatment has given the best re- 
sults. I have generally prescribed the mercuric bichloride, 1 / 16 grain, 
and the potassium iodide, 5 or 10 grains, to be taken three or four 
times a day in 1 drachm of syrup of sarsaparilla, well diluted. The 
doses are increased in size as tolerance will permit, care being taken 
that the stomach is not deranged by them. The ulcerations may re- 
quire local treatment, such as has already been given under the head- 
ing of "Syphilis of the Pharynx." J. Solis-Cohen's favorite topical 
application consists of cupric sulphate in crystals or in solution, or 
chromic acid, 1 part in 4 or 10 parts of water. Xosophen and aristol 
may be dusted over the ulcers with the throat powder-blower (Fig. 83). 

Paralyses usually yield to the constitutional treatment, but it 
may be advisable to employ electricity and strychnia. 

Contractions and tumefactions may occur sufficiently to cause 
strictures and stenosis of the larynx. If the interference with respi- 
ration is considerable, the aponeurotic membrane and other adven- 
titious tissue must be incised or removed (Fig. 102), or they can 
be divided and destroyed by means of the galvanocautery. When ex- 
treme stenosis threatens suffocation, intubation or tracheotomy must 
be performed. Since the cicatricial tissue of syphilitic origin is little 
susceptible of dilatation, a tube may have to be worn permanently 
after tracheotomy. Schrotter has devised laryngeal dilators to be 
inserted at first by the surgeon and later by the patient. These are 
left in position as long as the patient can endure them, using sizes 
of increasing calibre. They are used daily to increase the lumen of 
the laryngeal aperture, taking from six to eighteen months to effect 
a permanent dilatation. 



CHAPTER XXVII. 
DISEASES OF THE LARYNX (Concluded J. 

TUMORS. 

For convenience of description, tumors of the larynx are con- 
sidered under two main headings, — "Innocent" and "Malignant" 
tumors. 

INNOCENT TUMORS. 

Benign, or non-malignant, tumors of the larynx arise as the 
result of various kinds of irritation, — such as inordinate use of the 
voice, great exposure to cold and wet weather, inhalation of air con- 
taining much dust, especially of a metallic nature, etc. 

Papillomata. 

Papillomata are more common than any other form of tumors 
of the larynx (Plate VII). They present widely-differing variations in 
size and physical appearances. They may he white or a light-red 
color, and the size of a hean or less, sessile and rough, single or mul- 
tiple. Others resemble gray warts, springing from the vocal cord like 
little cones. These are most common in adult life. Children or 
young people are often subject to laryngeal papillomata, which as- 
sume a multiple form comparable to the raspberry or miniature cauli- 
flower. They are rapidly regenerated after being removed. Indeed, 
all of these varieties may recur; but they may be very slow in return- 
ing, or they may not be reproduced at all. 

Papillomata develop, not only on the vocal cords, but on the 
ventricular bands, and on the aryepiglottic folds, and they may attain 
to such numbers or size as to occlude a view of the cords, interfere 
with respiration, and stifle the voice. A guarded prognosis must be 
given when a papillomatous growth is found on one side and above 
the cord, or upon its margin in elderly people, since it is suggestive 
of laryngeal cancer. Indeed, laryngeal papillomata are prone to un- 
dergo transformation into carcinomata. (See "Treatment," page 314.) 

(312) 



PLATE VII. 



PLATE VII. 



Figure 22. — Syphilitic infiltration of the arytenoid cartilages and the right 
vocal cord; gummata of the right half of the epiglottis. 

Figure 23. — Tertiary syphilitic ulceration of the epiglottis and the right aryt- 
enoid cartilage; great thickening and congestion of the epiglottis and of the aryt- 
enoid cartilages. 

Figure 24. — Pachydermia laryngis, the growth springing from- the posterior 
portion of the left vocal cord, causing a corresponding depression in the right cord. 

Figure 25. — Pachydermia of the larynx, twin tumors springing from the poste- 
rior portions of the vocal cords; the convex surface of the left growth fits into a 
corresponding depression in the right. 

Figure 26. — Pachydermia laryngis located in the interarytenoid space. 

Figure 27. — Papilloma growing from the anterior portion of the right vocal 
cord, preventing close approximation of the cords in voice-production. 

Figure 28. — Papilloma of the left vocal cord, presenting an appearance sug- 
gestive of a raspberry. 

Figure 29. — Multiple papilloma of the larynx completely covering the vocal 
cords. 

Figure 30. — Fibroma of the right vocal cord producing hoarseness and, finally, 
aphonia. 

Figure 31. — Carcinoma of the larynx, ulceration and necrosis of the left aryt- 
enoid cartilage, and paralysis of the left vocal cord. 

Figure 32. — Unilateral paralysis of the adductors of the left vocal cord, as seen 
during an effort at voice-production. 

Figure 33. — Unilateral paralysis of the left abductor, as seen in forced inspira- 
tion. The left cord is in the cadaveric position. 






PLATE I7II 




29 




TUMORS OF THE LARYNX. 313 

Fibromata. 

Fibromata usually develop near the anterior extremity of the 
vocal cord (Plate VII). These tumors vary from a gray to a deep- 
red color, and they may be attached by a broad base or by pedicles. 
They are generally solitary, and present a smooth surface, but when 
a large size is attained they may become lobulated. Their size varies 
from that of a small pin-head to a pea, or, indeed, they may fill the 
larynx; but such an enormous development is seldom seen. "When 
touched with an instrument they impart the feeling of a firm, dense 
tissue. Their removal is followed by more satisfactory results than 
obtain after operations on other tumors of the larynx, for they do 
not often reappear. (See "Treatment," page 314.) 

Miscellaneous. 

Other very rare specimens of growths may be found in the larynx. 
Polypoid excrescences, such as mucous polypi, or myomata, sometimes 
make their appearance in the vicinity of the anterior commissure. 
They are attached by peduncles, and have a pale or red, smooth sur- 
face. Occasionally the epiglottis is the seat of a cystic tumor which 
presents a regular, rounded surface. 

Vascular, fatty, and cartilaginous tumors are so very seldom met 
with as to require a description in exhaustive works only. The symp- 
tomatology and treatment are the same for these as for laryngeal 
tumors generally. 

Symptomatology. — The symptoms are those characteristic of ob- 
struction to respiration, phonation, and deglutition. Kespiration is 
not interfered with in the early history of a laryngeal growth unless it 
is located in close proximity to the vocal bands or unless it is of rapid 
growth, so as to attain a large size and materially encroach upon the 
lumen of the respiratory space. With the increase in the bulk of the 
tumor, difficulty in respiration increases until it may end in asphyxia, 
unless relief is afforded. The voice may not be impaired if the tumor 
is situated sufficiently above the vocal cords to prevent any embarrass- 
ment of their vibrations. Should the growth be located on one of 
the vocal cords it acts like a damper, impeding the movements of the 
cord in response to the column of air, and, if it rest between the 
cords, it prevents their approximation and not only causes dysphonia, 
or difficulty in the production of the voice, but it changes its quality 
and interferes with respiration. The vocal bands then cannot be 
normally approximated, and the breathing-space between the cords is 



314 



TUMORS OF THE LARYXX. 



lessened in degree, according to the size and shape of the growths. 
Difficulty in swallowing occurs as a result of the location of the tumor 
where it prevents closure and perfect coaptation of the epiglottis over 
the entrance to the larynx. If it is seated upon the posterior surface 
of the epiglottis, as it presents in the laryngeal mirror, the same effect 
may be produced. Cough may or may not be a symptom, but it may 
be present as a result of the inability to evacuate easily the accumula- 
tions of mucus, which then act like a foreign body, or in case the 
tumor is of such a kind as to vibrate in the currents of air and thus 
produce a tickling or cough-provoking irritation. Patients with be- 
nign tumors seldom complain of suffering pain. 

Prognosis. — So far as the question of life is concerned, one is able 
to give a favorable prognosis in the case of an innocent laryngeal 




Fig. 102. — Tobold's Set of Six Forceps, Knives, etc. 

neoplasm. Should the growth reach such proportions as to render 
death imminent by asphyxia, tracheotomy will avert a fatal termina- 
tion. If the tumor be not removed by an endolaryngeal operation, 
thyrotomy may be resorted to, although the effect on the voice is 
better in endolaryngeal operations, more especially when the tumors 
are readily accessible and pedunculated. As has been already re- 
marked, there is a strong tendency to regeneration of the growths 
after operations for the removal of papillomata. 



Treatment of Innocent Tumors of the Larynx. 

There are numerous methods for the removal of tumors of the 
larynx. Forceps, knives, and curettes (Fig. 102) have been devised 
for this purpose. Snares, the galvanocautery, and caustics are in 
general use to effect the same results. 



TUMOKS OF THE LARYNX. 



315 



When the growths have not attained a considerable size and are 
not easily engaged in an instrument, chemical caustics are applicable. 
Before any operative procedure the interior of the larynx should be 
anaesthetized with a 20-per-cent. solution of cocaine. Chromic acid, 
preferred by Jarvis, is fused into a bead of proper size and shape on 
the flexible applicator (Fig. 182) and accurately applied to the surface 
of the growth. Silver nitrate can be similarly employed, fused in the 
same manner on the platinum-wire loop of the applicator. 

In making applications of caustics, or in manipulating any in- 
struments in the larynx, the operation is done by the aid of the laryn- 
geal mirror, so that every movement and the relations of all the parts 




Fig. 103. — The Author's Long Antero-posterior Laryngeal Forceps 

with Biting - Edges. 



can be closely watched. It must not be forgotten that the movements 
of the instruments in the larynx are directly opposite to the move- 
ments as seen in the mirror, everything being reversed. The utmost 
care must be exercised, or injury will be inflicted on the surrounding 
tissues that will be, perhaps, far more serious than the original 
trouble. 

Lennox Browne prefers the snare for the removal of growths. 
Dundas Grant has devised guarded cutting-forceps that take as firm 
a grip upon the tumor as Mackenzie's instruments. Much care must 
be exercised that a tumor once severed from its attachment does not 
drop back into the larynx as it is being removed. Evulsion of laryn- 
geal tumors is preferred by some operators. For this purpose the 



316 LARYNGEAL PAPILLOMATA. 

strong forceps of the author afford a firm grip upon the growths (Figs. 
103 and 107). These instruments are used without great difficulty if 
the larynx is properly anaesthetized. This is accomplished if the 
cocaine solution is applied two or three times at intervals of five min- 
utes. The benumbing effect of cocaine in the larynx is very transi- 
tory, not extending over ten minutes, so that operative measures must 
not be prolonged without renewed anaesthesia. 

The following case presents a unique feature, in that it was im- 
possible to remove all of the laryngeal growths with any instruments 
that were obtainable, but that no difficulty was found in operating 
with the special instrument shown in Fig. 103. The case was that of 
a man 50 years old. In 1895 he had experienced some annoyance 
from hoarseness; in December, 1897, he had a "cold in his throat," 
resulting in a loss of voice for two days; in the following summer the 
hoarseness returned and grew worse until, in November, 1898, there 




Fig. 104. — Laryngeal Papillomata. 

was complete suppression of the voice. The aphonia remained until 
the last of the papillomata were removed in January, 1900. 

Examination disclosed the condition shown in Fig. 104. The 
anterior commissure was filled by a pale-pink, lobulated mass resem- 
bling certain adenoid growths in the vault of the pharynx. Adjoining 
this mass was a growth on the left vocal cord, situated a little nearer 
the anterior than the posterior end. Nearly opposite this was a 
similar, though larger, tumor having a broad base, and project ing 
from the border of the band to meet the opposite tumor in such a 
manner as to bring its anterior surface in contact with the posterior 
surface of its fellow. The pressure of these two papillomata against 
each other produced a marked depression in the right one. These 
twin tumors presented the appearance of gray warts of a minute 
cauliflower formation, and together with the third growth occasioned 
not only suppression of the voice, but obstruction to the column of 



LARYXGEAL PAPILLOMATA. 317 

air, although the respiration was not yet embarrassed sufficiently 
to cause great distress. 

My first efforts were directed toward the removal of the mass 
filling the anterior commissure. I attacked it with Mackenzie's biting 
forceps and with the crushing forceps, but found that none of the 
usual instruments would reach it; then I bent an electrode in such a 
way as to afford a very long laryngeal extremity, and with this I 
destroyed the large mass. 

However, the patient was averse to the use of the electrode, and 
conceived the idea of having an extralaryngeal operation, but for- 
tunately was convinced that the results of endolaryngeal operations 
were far superior to those obtained from entering the larynx from 
without. By using the longest Mackenzie biting forceps obtainable 
I removed the mass shown at the actual size in Fig. 105. The larynx 
was situated so low that it was necessary to press with extraordinary 





Fig. 105. — Laryngeal Papillomata. Fig. 106. — Laryngeal Papillomata. 

force on the forceps in order to reach low enough to obtain this much 
of the growths, and it was impossible to reach more with the instru- 
ments then in use. Dr. 0. J. Stein kindly made attempts with his, 
and had the same results. 

Then I had an especially long biting forceps made, with which 
I was able to remove the remnants of the two neoplasms. After the 
one on the right cord was taken away, there was revealed a growth 
below the cord, which was readily reached and removed by directing 
the long cutting blades of the forceps well under the band. Fig. 106 
shows the actual size of the growths that were taken entirely by the 
special instrument (Fig. 103), which is three-fourths of an inch 
(eighteen millimetres) longer in the laryngeal extremity than the 
longest instrument I could find. 

Since the operation the voice has gradually improved in strength 
and timbre, and under date of March 11, 1900, the patient reported 
as follows: "I am most delighted to inform you that my voice con- 



318 PACHYDERMIA LAEYXGI8. 

tinues to improve; it is now almost normal, or as good as it ever was. 
I can halloo and, I believe, make a very fair stump speech/' etc. 

In another similar case it was impossible to engage in the jaws 
of the forceps several papillomata that sprung from the surface below 
the anterior insertion of the vocal cords. The writer then devised a 
biting forceps corresponding in ever}- particular to the long ones 
shown in Fig. 103, except that they opened laterally instead of antero- 
posteriorly. With this instrument (Fig. 107) most of the tissue was 
removed, but enough remained to necessitate the use of the electric 
cautery. However, no electrode that could be found was of sufficient 
length to reach the seat of the growths. The author then constructed 
the laryngeal electrode shown in Fig. 108, with which he experi- 
enced no difficulty in thoroughly cauterizing the attachments of the 
growths. 

When operating in the larynx, one ought always to have his 
tracheotomy instruments at hand, for instances have occurred in 
which spasm of the glottis has immediately followed the procedure, 
necessitating opening the larynx to prevent a fatal surf ocation. 

Ephraim Cutter was the first to perform laryngotomy for the 
removal of a laryngeal tumor. This must sometimes be done when 
the growth cannot be extracted in the usual way. An incision is made 
into the angle of the thyroid cartilage, the tumor removed, and the 
wound closed. 

Pachydermia Laryxgis. 

Virchow and Friinkel were amono; the first to describe a thick- 
ening of the mucous membrane covering the free edges of the vocal 
cords and lining the interarytenoid space, and especially in the region 
of the vocal processes (Plate VII). 

Pathology. — There is a great increase in the thickness of the 
epithelium, and in the number of papillae, and horny changes in the 
outer cells. The tendency is to the formation of oval tumors, and 
when they occur on the vocal cords there are frequently two seated 
opposite each other. In this case the apex of one iit.> into a depres- 
sion in its fellow. The interarytenoid pachydermia is not so often 
seen as the growths upon the cords. The color i> whitish gray or 
possibly pink. 

Etiology. — Pachydermia is found more often in middle-aged men 
than in women, and they are probably caused by excessive use of the 
voice, tobacco, and alcohol. 



PACHYDERMIA LARYXGIS. 



319 



Symptomatology. — There are huskiness of the voice, sensations 
akin to a foreign body, possibly dull aching, and even labored breath- 
ing and painful swallowing. The neoplasms may attain to so large 
a size as to suppress the voice. In such cases the tumors assume a 
pink color. 

Diagnosis. — The symptoms are generally much less pronounced 
than in malignant disease. The interarytenoid growth is suggestive 
of tubercular infiltration, but the latter is more clearly defined, is of 
a deeper red color, and produces more disturbance than the former. 
Moreover, pachydermia more often occurs in the form of symmetrical, 
or twin, tumors on some part of the free margins of the vocal cords. 
The unilateral form of this tumor, known as singer's nodule, might 
be mistaken for a fibroma. Pachydermia is found most frequently on 
the posterior portions of the vocal cords, while cancer generally occurs 
on the anterior parts. 




Fig. lor. — The Author's Long Lateral Laryngeal Forceps with Biting 

Edges. 

Prognosis. — The outlook is favorable to life, but unfavorable in 
respect to the voice, when the growths occur on the vocal cords. 
When they are situated in the interarytenoid space the vocal func- 
tions may not show impairment. 

Treatment. — Measures should be first addressed to the correction 
of any catarrhal conditions that may be present, along the lines al- 
ready laid down in previous pages. In addition to local treatment 
potassium iodide should be administered in moderate doses. When 
the voice is affected, strong astringents, such as a 10-per-cent. solu- 
tion of silver nitrate, may be applied, or the electric cautery may be 
resorted to. If the tumor is of sufficient size to permit grasping it 
with instruments, it should be crushed by the biting forceps (Figs. 
103 and 107). 






320 MALIGNANT TUMORS OF THE LARYNX. 

In a discussion on this subject before the Twelfth International 
Medical Congress > in Moscow, August, 1897, Heryng spoke of the op- 
erative treatment of the vocal cords affected by a pachydermatous 
condition resulting from repeated attacks of catarrh. He remarked 
that "it was not the beautiful pearly-white cords that produced the 
finest voices, this pearly whiteness often being produced by numerous 
layers of thickened epithelium. Some of the best singers had dis- 
tinctly red, catarrhal-looking vocal cords; for example, Jean de 
Reszke's vocal cords were slightly red before, and very red after, sing- 
ing. One should be in no hurry to treat a singer's larynx in any 
radical way." He especially warned young laryngologists to be ex- 
tremely careful in their dealings with singers. It is easy to under- 
stand why pachydermia is frequent among them. They are exposed 
by the nature of their calling to frequent catarrhal attacks; they are 
prevented from obtaining proper treatment for each attack; they are 
compelled to sing whether it prove detrimental to their voices or not; 
and, although overindulgence in eating, drinking, and smoking are 
destructive to singing voices, "nearly every singer smokes too much, 
eats too much, and drinks (alcoholic beverages) too much. By these 
means a slight catarrh or cold easily becomes chronic, and proceeds 
to produce pachydermia." (Medicine, March, 1898.) 

MALIGNANT TUMORS. 

Malignant growths of the larynx are not uncommon. They may 
be classed as carcinomata and sarcomata. 



Carcinomata. 

These are commonly known as cancers (Plate VII), and are, by 
far, the most frequent of malignant growths in this locality. Bos- 
worth reported, as a result of a collective investigation of the subject, 
that, out of three hundred and thirty-four published cases of malig- 
nant growths, two hundred and four were cancers and one hundred 
and thirty were sarcomata. 

There is considerable variation in the nomenclature of this sub- 
ject. Browne treats of cancer under two headings: "Epithelioma" 
and "Alveolar Epithelioma" (adenoid, scirrhous, or encephaloid can- 
cer). These growths may occur as primary diseases of the larynx or 
they may result from an extension to this organ from adjacent tissues. 



CARCINOMATA OF THE LARYNX. 321 

Pathology. — The identity of epithelioma cannot be determined 
positively by the mere evidence of a microscopical examination show- 
ing a proliferation of epithelium and cell-nests. It is settled that 
•the process is of a malignant character only when the epithelial pro- 
liferating process invades the underlying connective tissue and its 
infiltrating nature is established. The disease more often originates 
on the ventricular bands than on the vocal cords. In the early stage 
of cancer the tissues present an hypersemic and indurated appearance, 
which gradually extends to the surrounding structures. The thick- 
ening increases irregularly until a more or less well-defined tumor 
results; the enveloping membrane softens, breaks down, and the 
stage of ulceration is established, with its widespread destruction of 
the parts involved. Excision of a deep portion of the growth may be 
made for a microscopical examination. 




H 



Fig. 108. — The Author's Laryngeal Cautery Electrode. 

Etiology. — Heredity is an important etiological factor, and any 
occupation or habit that excites a constant irritation of the tissues, 
according to'Virchow, may result in converting an innocent neoplasm 
into a malignant growth. Cancers usually do not occur before the 
fortieth year. 

Symptomatology. — The effect upon speech and articulation will 
depend upon the situation of the tumor. If it belong to the intrinsic 
form, — that is, if it attack the subglottic space, the vocal cords, the 
ventricles, or the ventricular bands, — the voice is more or less seri- 
ously affected. Should the growth be limited to the arytenoid carti- 
lages, the sinus pyriformis, the aryepiglottic folds, or the epiglottis, 
thus constituting an extrinsic laryngeal neoplasm, the voice may not 
be markedly changed. When infiltration extends to and includes the 

21 



322 CARCINOMATA OF THE LARYNX. 

laryngeal muscles, interfering with their functions, the voice is 
altered according to the muscles affected. Hoarseness may exist 
from near the beginning of the growth, and later the voice may be 
entirely lost. 

In the intrinsic form not only the voice, but respiration, is em- 
barrassed. Cough may not be present until ulceration has occurred, 
when a purulent expectoration appears. In deep erosions, necrotic 
tissue stained with blood and characterized by a very offensive odor 
appears in the sputa. In the final periods of the disease difficult deg- 
lutition is present, especially in the extrinsic variety of tumor. 

Pain, the label of malignant growths, is an invariable symptom. 
It is likely to radiate through the neck into the pharynx, and, as 
occurs in tuberculosis of the larynx, it extends to the ears. So con- 
stant and -conspicuous a symptom is the involvement of the ears in 
pain that von Ziemssen considered it pathognomonic of laryngeal 
cancer. The general appearance of the patient after a long duration 
of the disease corresponds to the condition called by that classical 
alliterative term "cancerous cachexia." 

Inspection shows the location of the growth. At an early date 
only a thickened or nodular condition of the mucosa may appear, of 
a gray or deep-red color. When the epithelium is desquamated and 
the ulcerative process is established, a granular proliferation of the 
tissues springs up about the border of the erosion. Fungoid growths 
are seen sprouting from the surface of the ulcer, only to succumb 
to the necrotic process later. As the disease advances the destructive 
process becomes so great as to cause abscesses; the cartilages are at- 
tacked, and portions of necrosed cartilage are loosened and expecto- 
rated; haemorrhages occur; the breath is foul; the larynx becomes 
constricted, and, unless surgical interference be resorted to, death 
ensues. 

Diagnosis. — Laryngeal cancer is not always easily distinguished 
from other affections in which there is tumefaction or ulceration 
In chronic hypertrophic laryngitis and in pachydermia laryngis the 
hyperemia and thickening of the mucous membrane simulate the 
early stage of cancer, but in the former diseases we will note the ab- 
sence of pain, ulceration, infiltration of the cervical glands, and the 
microscopical appearances. However, it should not be overlooked 
that a microscopical examination of a section of a tumor may show 
that the portion removed is non-malignant, while it does not prove 
that the whole growth is benign. 



CARCINOMATA OF THE LARYNX. 323 

The author could cite repeated instances in which many careful 
microscopical examinations have been made by different bacteriolo- 
gists, when their conclusions were not borne out by the ultimate 
clinical results. So frequently are the histological evidences, inter- 
preted by the microscope, negative in character, it is all the more in- 
cumbent on the clinician to exercise the utmost patience and skill in 
determining the differential diagnosis. 

In this connection it is interesting to recur to the discussion on 
this subject which took place at the meeting of the Twelfth Inter- 
national Congress, at Moscow, in August, 1897. Chiari reported 70 
cases of carcinoma laryngis occurring under his own observation. 
Comparing the clinical with the microscopical diagnosis, he main- 
tained that, when the clinical evidences favored a diagnosis of cancer, 
a negative microscopical examination was not to be considered, whereas 
positive microscopical evidences obtained by a thoroughly competent 
microscopist must outweigh clinical evidences to the contrary. 

Hajek claims that intrinsic and extrinsic carcinomata of the lar- 
ynx are to be put into two totally separate categories, the former 
being much milder in its course than the latter, on account of the very 
poor supply of lymphatics to the lan^nx. Carcinoma on the poste- 
rior wall of the larynx is rare; when occurring at that situation it 
is difficult to diagnose. Pachydermia, as a rule, occurs on the poste- 
rior parts of the vocal cords, whereas cancer occurs on the anterior 
portions. Pachydermia is almost always bilateral, but cancer is uni- 
lateral. "The lazy, limited movement of the vocal cord, so much 
spoken of in cancer, is hardly a trustworthy symptom, because it is 
often absent in cancer and present in pachydermia. Much more 
valuable is the fact that pachydermia appears, on laryngeal examina- 
tion, to be a growth on the vocal cord, while a commencing carcinoma 
does not appear as a growth at all, but rather as an indefinite thick- 
ening of the cord itself, of which one cannot say where it begins and 
a healthy cord ends." (Medicine, January, 1898.) 

From papilloma, cancer may be distinguished by the facts that 
these warty growths occur in early life, as a rule, while carcinoma is 
usually found in persons past middle life. Papilloma is a more clearly 
defined tumor, while cancer presents an irregular infiltration and 
thickening. The cancerous cachexia and pain, also, are to be remem- 
bered as characteristically distinguishing features. If the cancer be 
extrinsic, enlargement of the lymphatic glands in the vicinity may be 
found. 



324 CARCINOMATA OF THE LARYNX. 

In tuberculosis of the larynx there are the characteristic cough, 
pulmonary complication, history of consumption, lighter color, and 
less swelling of the tissues preceding ulceration. After ulceration 
sets in it is not likely to erode the tissues as deeply as cancer does. 
The absence of the bacillus of tuberculosis is only negative bacterio- 
logical evidence, for the author has watched the destructive process 
do its deadly work through long, weary months to a fatal termination, 
while various microscopists and bacteriologists utterly failed to dis- 
cover a single bacillus. 

From syphilis it is sometimes difficult to distinguish epithelioma, 
especially from the gummatous stage of the former. Gummata, how- 
ever, ulcerate early in most cases. The question is simplified if the 
history be obtainable. Comparing the ulcerative stages of the two 
diseases, it is not an easy problem to solve. Now comes the most 
reliable test. If it be syphilis, the exhibition of the iodides will cause 
a progressive clearing up of the symptoms, and the improvement con- 
tinues; while, in the case of cancer, although there may be a per- 
ceptible improvement for a short time, this benefit is soon lost and 
the patient retrogresses in spite of the iodides. But the syphilitic 
increases in weight, and shows a general improvement as well as 
marked mitigation of the local symptoms. 

From innocent growths it may be exceedingly difficult to dif- 
ferentiate cancer in its early history, but the manifestations of the 
cancerous tumor are more pronounced than those of non-malignant 
neoplasms. The pain, age of the subject, and the appearances of the 
various tumors already described, taken with the history of the case, 
will form a group of facts that will tend to the formation of a cor- 
rect diagnosis. 

Prognosis. — According to Mackenzie, the average duration of 
the encephaloid cancer of the larynx is three years. Browne gives 
twelve months as the limit of life after removal of epithelioma. The 
results of tracheotomy are more favorable than those of thyrectomy 
or thyrotomy. No operation cures; starvation, haemorrhage, or as- 
phyxia ends life. 

Treatment. — By certain methods of treatment life may be pro- 
longed and rendered less miserable. From a humanitarian point of 
view, if it were justifiable under any hopeless circumstances to relieve 
a fellow-being of his misery and despair by the merciful production of 
< ul hauasia, cancer of the larynx is that case. Death constantly stares 
his victim in the face, and, what is worse, like the burning coal in 



SARCOMATA OF THE LARYNX. 325 

the eye of Cyclops, pain, in all its variations and refinements of 
torture, converts the patient's world into a chamber of horrors. No 
words can depict the agonies of these coughing, choking, strangling 
sufferers. 

Local anaesthetics and anodynes must be added to detergents 
and antiseptics. Sprays of cocaine and morphia in ethereal solutions 
are indicated for the alleviation of pain. Aristol and iodoform may 
be used in the same manner. 

Chloroform and belladonna liniment may be employed for ex- 
ternal applications. Steam-inhalations containing conium and ben- 
zoin may prove grateful. 

One should bear in mind that there is always a possibility of a 
syphilitic taint, which would yield to specific treatment, and a trial 
of the effects of sodium or potassium iodide should be made. 

Operative measures may relieve the immediate suffering from im- 
pending suffocation, and they may prolong life for several months. In 
October, 1895, Eoswell Park reported a case of total extirpation of 
the larynx for epithelioma. Fourteen weeks after the operation the 
patient presented himself at the clinic "the picture of health." Op- 
erations within the larynx are deprecated by some authorities: 
Browne and Newman. Galvanocauterization produces only tempo- 
rary benefit. Tracheotomy offers the greatest promise of relief from 
suffocation and may prolong life from two to four years. 

Chiarr's best results have been obtained from an operation, laryn- 
gofissure, when it is required to excise a vocal cord or false cord only. 
"This method, which is not attended by danger, insures a good voice 
and respiration, and it obviates the necessity of wearing a tube." It 
is only for intrinsic carcinoma that partial or total resection should 
be practiced. Krause maintains that the results from laryngofissure 
are not often permanent, recurrence taking place some time later. 
In fourteen of his cases treated by total extirpation of the larynx 
there was but a single death. In these cases the new method — in 
which the end of the trachea is stitched to the skin — was employed. 
This closes the communication of the trachea with the throat by 
stitching the mucous membrane, and by the use of tampons. 

Sarcomata. 

These are very rare tumors of rapid growth, and attain to a large 
size. Their appearances differ widely, sometimes resembling fibro- 
mata or papillomata. Only a microscopical examination can give a 



326 FOREIGN BODIES IN THE LARYNX. 

positive diagnosis. They do not kill as quickly as epithelioma doe?, 
but are destructive of life sooner or later. They should be removed 
by some of the methods already described for the extirpation of other 
tumors. Max Toeplitz reports a case of chondrosarcoma cured by 
intralaryngeal operation. 

Foreign Bodies in the Larynx. 

During inspiration while eating, or in the act of laughing, foreign 
bodies are drawn near or into the larynx, where they find lodgment. 
Lefferts reported a case in which a brass watch-ring became imbedded 
so as to rest astride the aryteno-epiglottic fold and ventricular band, 
where it remained four years. 

Symptomatology. — The presence of any foreign body in the 
larynx excites most violent coughing and symptoms of strangulation. 
If the body is of such a size and contour as not to completely fill up 
the lumen of the canal, breathing may proceed until the reflex spas- 
modic efforts at dislodgment succeed in expelling the body. "When 
the entrance to the larynx or the glottis is completely obstructed, suf- 
focation may take place before relief can be obtained, the patient 
dying in a few minutes. Boluses of meat and other soft substances 
that apply themselves closely to the inequalities of the cavity are the 
most common causes of death from foreign bodies. But rough bodies 
may set up such an inflammation before their extraction that oedema 
of the larynx or pneumonia may result. 

If the body is coughed up, considerable soreness and pain may be 
experienced for a few days afterward. Small foreign particles some- 
times remain for a long time in the larynx before being thrown out 
by coughing or sneezing. They may give rise to an irritation that 
leads to a serious lesion of the mucosa. 

Treatment. — The finger can sometimes be made to reach and dis- 
lodge the body if it is in the vicinity of the entrance to the larynx. 
A common remedy is to slap the patient on the back of the shoulders 
just as he makes an expiratory effort. Gravity may be brought into 
play in case of a foreign body with some material weight. The pa- 
tient may be held with the feet upward and the head pendent while 
expulsive efforts are made by the patient. 

Sharp-pointed articles penetrate the walls of the larynx suffi- 
ciently to arrest their onward progress, and the coughing, retching, 
and gagging serve to force them farther into the tissues. All the 
sensitive area should be treated to a 20-per-cent. solution of cocaine, 



FOREIGN BODIES IN THE LARYNX. 327 

and by the aid of a mirror the object should be located. Then the 
laryngeal forceps (Figs. 103 and 107) may be made to grasp and ex- 
tract the offending invader. 

If failure attend the attempt to extract the foreign substance, 
and strangulation is impending, tracheotomy must be done without 
delay. If proper instruments are not at command, a pocketknife 
will do, and retracting hooks can be improvised with safety-pins, hair- 
pins, or the like until sufficient conveniences can be supplied. 



PART IV. 



Diseases of the Bar. 



(329) 



CHAPTEE XXVIII. 

A GENERAL CONSIDERATION OF DISEASES OF THE EAR, NOSE, 
AND THROAT BASED ON A STUDY OF TWENTY- ONE THOUSAND 

CASES. 

The following statistical data represent the records of 21,000 
cases treated during seventeen years at one of the author's clinics in 
Chicago. The first series formed a part of a report made by the 
writer to the Ninth International Medical Congress, in 1887; the 
second was compiled for me by my assistant, Charles L. Enslee. A 
relatively small number of unselected cases have been added from the 
records of my private practice to supply the place of those whose rec- 
ords were incomplete. The first classification was instituted for the 
purpose of establishing a basis of calculation of the influence, if any, 
exerted by occupation, age, or sex in the causation of ear diseases. 
The condition of each patient at the time he first presented himself 
at the clinic is given in order to determine the relative frequency of 
the different diseases. 

As is common in charity hospitals, a considerable number of 
those who applied for treatment belonged to that class of laboring- 
people who have no definite trade or fixed occupation. In order to 
facilitate investigation and simplify the study as far as possible, all 
those occupations that were closely related to each other in nature 
and effects were grouped under one heading. For example, under 
the classification of clerks were embraced salesmen, bookkeepers, 
office employees, etc.; with teamsters were grouped car-drivers, ped- 
dlers, etc.; cooks and bakers were classed together; brass-molders, 
iron-molders, etc., were classified with iron-workers; plumbers, gas- 
and steam- fitters appear together; such closely allied occupations as 
stone-cutters, stone-masons, brick-layers, and plasterers, in which the 
influences and exposures are very similar, are grouped together under 
the head of day-laborers, — a term borrowed from the laborers them- 
selves. 

The combined data show that, of the 21,000 cases, there are 
11,167 patients with occupations, classified under 28 headings. Of 
this number, 3813 had out-door and 7354 in-door work. In the 

(331) 



332 CLASSIFICATION OF PATIENTS AND DISEASES. 

first study a larger proportion would undoubtedly have appeared as 
belonging to in-door occupations had as much care been exercised in 
eliciting the exact nature of the vocations of so-called day-laborers 
as was used during the time covered by the second study. About 34 
per cent, were out-door and 66 per cent, in-door occupations, or about 
twice as many in-door occupations as out-door. 

The largest number of any one class were in-door workers, — 
3014 domestic servants. Next in order were about half that number 
of the out-door class, or 1493 day-laborers. Then follow groups of 
the next highest numbers: 858 clerks, 460 iron-workers, 452 car- 
penters, 420 factory-workers of all kinds, and 400 sewing-women, — 
all in-door occupations, until we reach the out-door class again in 
going down the list. 

While the great stores and factories furnish a large number of 
patients, the homes contribute 5615 females, including the servants, 
seamstresses, and women without occupation, or more than one- 
fourth the whole number of the combined data. These facts are 
significant when we take into account the slight difference between 
the number of males and females affected under the age of 15 years. 
Out of 6154 children under 15 years there were 1484 boys and 1582 
girls between the ages of 6 and 15 years, and 1641 boys and 144T 
girls under 6 years. Of all these children 3029 were girls and 3125 
boys, leaving a difference of only 96 more males than females under 
15 years. Between the ages of 6 and 15 years there were 95 more 
girls than boys. Under 6 years there were 194 more males than 
females. 

Sex seems to have no influence in the production or prevention 
of diseases of the ear, nose, and throat. It appears that up to the 
age of 15 years both sexes suffer nearly equally. Possibly a reason 
for this may be found in the similarity of the lives and habits of the 
sexes during this early period. But the classes of society that afford 
clinical material at the medical charity institutions are such that 
necessity requires them to abandon the pursuit of an education at 
about the fifteenth year, and to enter upon bread-earning vocations. 
Thenceforth the divergence in habits and environments increases. 
The males are either out of doors more than ever or confined chiefly 
to mercantile houses and factories. The females become domestics, 
clerks, shop-girls, and seamstresses. 

An interesting question pertains to the relative frequency of 
diseases of the right and of the left ear, and Of diseases of one ear 



CLASSIFICATION OF PATIENTS AND DISEASES. 333 

as compared with, diseases existing coincidently in both ears. The 
second study shows that in acute inflammation of the middle ear 
there is but a very slight difference in the frequency of involvement 
between the two ears, not referring to the question of sex, and both 
ears were affected in 43 per cent, of all the cases. In acute sup- 
puration of the middle ear, again, there is too little difference be- 
tween the two ears to take into account. In 15 per cent, of all these 
cases both ears were involved. 

In 2790 cases of unilateral ear diseases which the author has 
investigated to determine which ear was the more frequently affected, 
especially with reference to the question of sex and its influence, 
first in children under 15 years of age, and, second, in adults, the 
results are as follow: There were 456 boys with affections of one ear 
only, of whom 245 had diseases of the right ear, and 211 diseases of 
the left ear, an excess of about 7.6 per cent, of right-ear affections. 
Of 569 girls, 334 had diseases of the right and 235 diseases of the 
left ear, or an excess of 17.4 per cent, of affections of the right ear. 
This shows that out of the total number of 1025 children under 15 
years there was an excess of 25 per cent, of diseases of the right ear. 

Of 1046 men, 472 had diseases of the right ear, and 574 of the 
left, or an excess of about 10 per cent, of affections of the left ear. 
There were 719 women, of whom 363 presented troubles of the right 
ear, and 356 of the left, or an excess of diseases of the right ear 
amounting to a trifle less than 1 per cent. 

In the 5809 cases of chronic non-suppurative inflammation of 
the middle ear the two sides were about equally affected, but a great 
contrast is now offered in the relative frequency with which both ears 
are involved in the various middle-ear diseases, for in this instance 
nearly 82 per cent, of all the cases presented bilateral aural affection. 
Sufficient importance must be attached to these undeniable figures 
in formulating our prognosis when only one ear is already diseased, 
for it follows, almost as the night the day, that if one ear has become 
seriously affected, especially with the sclerotic form of dry catarrh, 
the other falls under the same destructive process. 

In chronic suppurative otitis media the two ears suffer nearly 
equally, and it appears that both ears are simultaneously affected in 
a little more than 60 per cent, of the cases. In 3185 instances of 
unilateral ear diseases there was an excess of only 23 cases of the 
right over the left ear. This fact is mentioned particularly because 
the opinion has often been expressed that one ear was much oftener 



334 ETIOLOGY OF DISEASES OF THE EAR, NOSE, AND THROAT. 

affected than the other, some specialists believing that the right was 
by far the more frequently diseased. 

The data show that about 13 per cent, were afflicted with naso- 
pharyngeal diseases, but the actual number would be far in excess 
of this figure. The institution being an eye and ear hospital strictly, 
not as great prominence has been given to the nose and throat affec- 
tions as would be desirable, this part of the diagnosis sometimes be- 
ing entered on the patients' cards instead of upon the record-books. 

About Vio °f 1 P er cent, had diseases of the mastoid process, 
which was nearly twice as prevalent in males as in females. 

Deaf-mutes formed about 1 / 2 of 1 per cent, of the 21,000 cases. 
There were three times as many males as females. 

The largest number of any one class of diseases was 8827 with 
chronic non-suppurative inflammatory processes of the middle ear. 
or 42 per cent, of the whole number. Xext in numerical order come 
3664 cases of chronic suppurative inflammation, or 17 per cent.; and 
the next highest number 1009 cases of acute suppuration, or 5 per 
cent. 

American residences and business houses are heated in cold 
weather by dry, hot air and kept at a temperature of 70° F. or 
higher. The inmates are subjected to the action of this dry heat, 
often laden with dust and noxious gases, the greater part of every 
day. The skin, consequently, is very active in its functions, and 
kept moist by free perspiration. But, though constant exposure 
renders the soldier, Spartan-like, indifferent to cold and storms, 
housing the body makes it tender, like the hot-house plant, and 
sensitive to sudden and extreme changes in the air. After working 
all a winter-day in a temperature of summer-heat, these people, with 
the powers of resistance reduced by fatigue and hunger, pass out 
immediately into a frigid atmosphere, with the temperature perhaps 
from 40° to 70° F. lower than that of the workshop. The skin is 
chilled, the perspiration checked, and a determination of blood to 
some internal organ occurs. Naso-pharyngeal catarrh is probably 
the most frequent consequence. This result is aggravated by high 
winds and the inhalation of dust. In fact, a very Large percentage o( 
naso-pharyngcal catarrh is undoubtedly due to the irritating effects 
of dust, and this, operating in conjunction witli cold, damp air. is 
largely responsible for the widespread existence of naso-pharyngeal 
catarrh among Americans. It is undoubtedly the most prevalent 
disease in the United States. The importance of this fact i> obvious 



ETIOLOGY OF DISEASES OF THE EAR, NOSE, AND THROAT. 335 

when we consider that so large .a number of middle-ear affections 
originate in naso-pharyngeal inflammation which extends through 
the Eustachian tube to the tympanum. Critical examination of the 
nose demonstrates the existence of nasal trouble in a large proportion 
of these cases. Hence, whatever causes a catarrh of the nose and 
throat is interesting to the otologist as a proximate cause of ear 
disease. 

The exanthemata are frequent causes of ear diseases during 
childhood, but youth seems to predispose to coryza, which is often a 
forerunner of tubal and tympanic catarrh. Children under 15 years 
of age constitute about 29 per cent., or more than one-fourth of the 
whole number of cases. Very many of them dated back to attacks 
of scarlet fever, measles, and the earaches and "running-ears" of 
infancy; so that a much larger percentage than appears should prob- 
ably be credited to the period of childhood. Only a small proportion 
of children were brought for treatment during the acute stage of 
inflammation. Only about 10 per cent, were acute cases, leaving 90 
per cent., or nine times as many, who had not applied for treatment 
until the inflammation had reached a chronic stage. Indeed, only 13 
per cent, of the adults were seen in the acute stage. 

The data show a large percentage of diseases of the external 
ear. Since impacted cerumen may be regarded as a symptom and 
a consequence of chronic non-suppurative inflammation of the middle 
ear, due consideration should be given this fact in estimating the 
relative frequency of affections of the middle and of the external ear 
as shown in the data. 

It may be permissible to cite a few facts that do not appear in 
the statistics, but which, nevertheless, were impressed upon me by a 
personal study of this class of patients. Although the whole State 
of Illinois contributed largely to the number embraced by these ob- 
servations, a large majority were residents of Chicago, — a very cos- 
mopolitan city. The foreign element predominates. The national- 
ities were not recorded except in resident infirmary cases, but the 
Irish constituted a very large and the French a very small percentage 
of our clinical material. The north of Europe furnishes a far greater 
percentage of our population than the southern portions. After con- 
sidering the nationalities it will not be surprising when it is stated 
that the blondes exceed the brunettes in number. 

Another matter of interest to the etiologist, and to the student of 
sociology as well, was the conspicuous absence of baldness among 



336 COMPAKISON OF STATISTICS. 

these people, for cold draughts of air on heads deprived of Nature's 
covering are considered by some authors as being a prolific cause of 
catarrh. 

Loewenberg, of Paris, in the Deutschen medicinischen Wochen- 
schrift, arrives at the conclusion that ear diseases have a particular 
predilection for the left ear. He believes that if one ear only is 
diseased it is more frequently the left. If the affection attack both 
ears it generally begins in the left, and leads here often to a more 
profound malady and to a higher degree of deafness than with the 
right ear. In this respect the sexes differ, in that the predominant 
deafness of the left side is peculiar to the male, while the reverse is 
true of female patients. Loewenberg examined 3000 cases of im- 
paired hearing, excluding causes lying in the external ear. Of the 
whole number there were 1790 males and 1210 females. He found 
among those affected with one-sided deafness 478 men and 311 
women. Of these, the right ear alone was afflicted in 212 men and 
167 women, and the left ear alone in 266 men and 144 women. This 
leaves about 12 per cent, more men afflicted with deafness of the left 
than of the right side, and about 7 per cent, more women with right- 
sided than with left-sided deafness. 

Among those suffering from bilateral deafness 1074 men and 
737 women were found, the right ear being the worse in 427 men 
and in 340 women, and the left ear having the hearing more impaired 
in 647 men and in 397 women. There were 238 men and 162 women 
who were afflicted with a high degree of deafness affecting both ears 
equally. 

B. Alexander Eandall has reported 4785 patients with 5412 dis- 
eased ears. His table shows only slight variations in the relative fre- 
quency of diseases of the right ear as compared with the left, in the 
sexes. Among both men and women diseases of the right side pre- 
dominated in middle-ear affections, of the left side in external-ear 
diseases, and of the right side again in troubles of the internal ear. 
There is quite a wide difference between the conclusions arrived at 
from the Paris statistics and the deductions justified by the Philadel- 
phia and Chicago data aggregating 25,785 patients. During the 
past twelve years the author has taken pains to inquire of patients 
not only concerning the common causes of their varying diseases of 
the two ears, but also as to which ear they were in the habit of lying 
on usually, in order to ascertain if that question could have any bear- 
ing on the one-sided character of their diseases or on the fact of one 



CLIMATIC CAUSES OF DISEASE. 337 

ear being worse affected than the other in bilateral diseases, but no 
satisfactory solution of this problem has yet been evolved. 

This brings us to a consideration of the last topic of this chapter, 
— climatic causes. In speaking of climatic conditions as standing in 
a causative relation to these diseases, it should be understood that 
reference is had to those atmospheric conditions that are character- 
istic of the vicinity of the Great Lakes and the Mississippi Valley, 
although they may not be peculiar to it. A sudden great fall of tem- 
perature, accompanied with increased humidity of the air, is usually 
followed by an increase in the number of new patients with acute 
diseases of the ear, and of chronic cases with acute symptoms. These 
effects of atmospheric variations occur with such uniformity that we 
may predict an increase or decrease in the number of acute diseases 
with a reasonable degree of accuracy by observing the meteorological 
variations. Our climate is rugged, but the people born and reared in 
it do not seem to partake of its robust character. The altitude is low 
in the Mississippi Valley and the thermometric changes are sudden 
and great. It is not unusual for the thermometer to fall 20° or 30° 
F. or more in a few hours. Indeed, cold waves sweep suddenly over 
the country in summer-time, cooling the heated atmosphere so 
quickly and so thoroughly that one must needs change from summer 
to winter clothing with haste or suffer from the chilling winds. Add 
to these causes of great circulatory disturbances the irritating effects 
of constantly inhaled dust, which the ceaseless winds keep in never- 
ending motion, and the problem of the prevalence of naso-pharyngeal, 
tubal, and tympanic catarrh in our climate is, in a great measure, 
solved. 



CHAPTEE XXIX. 

EXAMINATION OF PATIENTS. 

The examination of patients should be conducted so systemat- 
ically that no discoverable pathological process can escape detection. 
Beginning with the right ear, both ears, the nose, and the throat 
should be minutely inspected. Patients often direct the surgeon's 
attention to one ear and remark that there is no trouble with the 
other, when examination reveals that both are affected in different 




Fig. 109. — The Author's Light-reflector and Screen. 

degrees. The examiner should not be misled, but should investigate 
for himself; otherwise he is not in a position to do credit to himself 
or his art or do justice to his patron. 

The aurist should sit facing the right side of his patient to begin 
the examination, with the light immediately behind the patient's 
head and on a level with his ear if it is an adult. In the case of a 
child the light should be on a level with the physician's eye. 

Time will be economized and labor facilitated by the use of an 
armless revolving-chair (Pig. 1) for the patient. The seat should be 
easily raised and lowered by a supporting centre-screw, fitted with 
sufficient nicety to prevent a rocking motion. The back should be 
very firm, and only high enough to support the patient's back beneath 
(338) 



EXAMINATION" OF PATIENTS. 



339 



his shoulders. After examining the right ear neither the physician 
nor the patient must rise to bring the left ear into the field of vision, 
for the patient's chair is easily turned half-way around, and the 
positions are correct to proceed, the lamp then resting in front of the 
patient. 

Excellent illumination is had from an Argand gas-burner, and it 
is now possible to obtain an incandescent electric lamp that will afford 
an evenly-diffused light such as the gas gives, but the mantles of the 
incandescent gas-burners are too easily broken to permit of their 
being used on adjustable brackets. The flame should be inclosed in 
a light-condenser (Fig. 109), not only to increase the effectiveness of 




Fig. 110. — Spring-band Mirror-holder. 



the illumination, but also to protect the operator's eyes. If the light 
is allowed to shine in one's eyes it contracts the pupils, interferes with 
perfect vision, and eventually impairs the sight. The condenser is 
constructed with a reflector instead of a lens. For this reason it is 
not top-heavy and requires no spring to hold it in place. By a slight 
stroke of the finger-nail or a probe, its position can be instantly varied 
without burning the finger. It fits over the Argand gas-burner or the 
large railroad-burners on oil-lamps. A special large size is made to 
fit the incandescent gas-burner. 

The three-inch forehead-mirror is worn over the eye that is next 
to the light, and the aperture in the mirror should fall opposite the 



340 



EXAMINATION OF PATIENTS. 



pupil of the eye engaged in inspecting the ear, so that both eyes are 
shielded from the direct rays of light. The light should be thrown 
in such a manner as to bring the auditory meatus within the focus of 
the reflected rays. Except at a distance of 14 inches or more, the 
drumhead is seen with one eye at a time; so that the other eye may 
be kept closed. The mirror is best held in position by a self -retaining 
holder, like the spring head-band shown in Fig. 110. This has the 
advantage of never deteriorating or becoming soiled, and, with prop- 
erly adjusted spring, it does not occasion the wearer a headache. It 
leaves the hair unruffled and is in every way more satisfactory than 




\ c:[p~:: £~ 



Fig. 111. — The Author's Adjustable Bracket. 



the cloth or rubber bands. The forehead-plate is lined with hard 
rubber, which renders it agreeable to wear and easy to cleanse. 

The light should be adjustable to the varying positions and 
heights of patients. To accomplish this the author devised the lamp- 
bracket illustrated in Fig. 111. The lamp is easily adjustable to any 
point lying within a perpendicular line two feet in length, and it will 
swing through the arc of a circle having a radius of three feet. The 
light may be placed either within a few inches of the surface to 
which it is attached or at a distance of three feet from the wall. To 
raise or lower the light it is necessary only to press the brake toward 



EXAMINATION OF PATIEXTS. 



341 



the arm above it, set the lamp at any desired level, release the brake- 
handle, and it then sets automatically. The gas is carried to the 
burner through a flexible tube, and where there is no gas an oil-lamp 
is substituted for the Argand burner. 

The metallic ear-specula are preferable to the hard rubber, but 
they should be warmed, especially in cold weather, before inserting. 
The small end of the funnel should be oval, to correspond with the 
contour of the meatus. 




1RAUX, SREENfc 4 CO 



O O O 

Fig. 112. — The Author's Ear-specula. 



The specula represented in Fig. 112 were designed by the writer 
a considerable time ago, and have been in constant use long enough 
to demonstrate some decidedly valuable qualities. They are much 
less cumbrous than the ordinary funnels, and the danger of injuring 
the drumhead is reduced to the minimum. They are made in three 
sizes, the smallest being twenty-five millimetres (about one inch) 
long, and the largest twenty-eight millimetres long (about one and 




OO o 



Fig. 113. — Gruber's Ear-specula. 



one-eighth inches). The interior is oxidized to prevent the reflection 
of light into the surgeon's eyes. In order to make them conform to 
the shape of the auditory canal the distal end is made oval. The 
funnel end is milled in order to prevent it from slipping from one's 
fingers, and its shortness and lightness render it less liable to fall 
from the ear. The cylindrical section bears such a relation to the 
conical portion as to guard against its insertion far enough to injure 
the drumhead. 



342 



EXAMINATION OF PATIENTS. 



In experimenting with different metals for ear-specula I found 
aluminum too weak and brittle. It bends out of shape and breaks 
too easily. The funnels made of brass and plated with silver are 
the most satisfactory, even preferable to solid silver. They are light 
and firm. These specula can be inserted far enough to slip within 
the antihelix, which holds them from falling out of the ear in many 
cases. 

Some of the funnels in use are very much longer than is neces- 
sary, and their insertion endangers the integrity of the membrana 
tympani. There are others that are too heavy and slippery, and they 
will not remain in position during examinations, treatments, and 
operations. Others do not conform to the contour of the meatus, 




Fig. 114. — The Author's Massage Otoscope. 



being circular throughout. The pigment used to blacken the interior 
of the funnels in common use is destroyed and removed by the cleans- 
ing and disinfecting or sterilizing processes. These specula, being 
oxidized, can be subjected to the action of strong carbolic-acid solu- 
tions, boiling, etc., without injury. 

The auricle needs to be drawn upward, outward, and backward 
in most cases to straighten the canal while the speculum is intro- 
duced, but in children it is sometimes necessary to draw the auricle 
downward and backward. 

A massage otoscope should be employed for diagnostic purposes 
as well as for treatment. In no other way can it be determined how 
much mobility of the ossicles has been lost, and how much is regained 



EXAMINATION OF PATIENTS. 343 

as the result of treatment. In 1887 the author devised the instru- 
ment shown in Fig. 114. It consists of a pneumatic chamber, a con- 
cave perforated mirror, and a lens, contained in a cylinder to which is 
attached forty-six centimetres (eighteen inches) of soft-rubber tubing 
and a diminutive air-syringe. The apex of the funnel is covered with 
a section of soft-rubber tubing to allow of its being fitted hermet- 
ically into the external auditory canal without causing discomfort. 
The mirror focuses the light upon the drumhead, and the syringe 
alternately rarefies and condenses the column of air in the air- 
chamber and meatus. The lens in the eyepiece gives a clear view 
of the drumhead and mallet under brilliant illumination and passive 
motion. By holding the otoscope with the axis of its cylinder at a 
right angle to the source of light, the rays are projected upon the 
drumhead. The easiest method is with the operator standing in 
front and a little to one side of the patient, the otoscope in the left 
hand for the right ear, and the right hand with the pump on the top 
of the patient's head. The position is reversed for the left ear. As 
soon as the light is thrown through the funnel the otoscope must be 



U4.-1IH ■HrHTTCTCTS 



Pig. 115. — The Author's Cotton-carrier. 

held steadily in its relation to the lamp, and if the drumhead is not 
in the field of vision the hand upon the patient's head must tip or 
turn his head until the drum is brought into view. Now the sight 
is fixed upon the hammer, while the piston-rod is drawn outward 
sufficiently to produce an outward excursion of the drumhead. Then 
it is pushed inward to condense the rarefied air and move the mem- 
brane inward. While these movements are being effected it is ob- 
served whether the mallet moves with the drumhead or not, and, if 
it does, how much freedom of movement is present as compared with 
the normal mobility. In some old cases of sclerosis the mallet re- 
mains entirely motionless, while the membrane about it vibrates. In 
the normal ear both move freely in response to every inward and out- 
ward motion of the air-piston. About three hundred of these move- 
ments can be made per minute if desired, and the otoscope can be 
operated either with or without its lens and mirror. 

No more force should be applied than is necessary to obtain the 
natural excursions of the drumhead and mallet, and ordinarily no 
discomfort is caused unless the funnel is pressed very firmly against 



344 



EXAMINATION OF PATIENTS. 



the canal-wall. If a deep blush overspread ShrapnelPs membrane and 
the mallet, the procedure should cease for the time, so as not to oc- 
casion too great hyperemia. The forehead-mirror is not needed with 
this instrument, since it contains its own mirror. Care must be taken 
to not allow the fingers to shade the reflector. 

The cotton-carrier is best made of soft silver, with round, 
twisted handle and roughened tip to engage the cotton (Fig. 115). 




Fig. 116. — Normal Drumhead of Right Ear. (After Politzer.) 

It should be very delicate, so as to consume as little space as possible 
in addition to the cotton twisted upon it. In many instances cerumen 
or discharges have to be removed before the drumhead can be in- 
spected. The cotton-carrier usually suffices, but the beginner must 
be reminded that the drum is more superficial in infants than in 
adults, and in no case should the membrana tympani be bruised. 




Fig. 117.— Normal Drumhead of Left Ear. (After Politzer.) 



The novice ought to accustom himself to the appearance of the 
normal drum by inspecting patients who have healthy ears. Students 
may profitably study each other. The healthy drumhead (Figs. 116 
and 117 and Plate VIII) has a pearly-blue tint, is translucent, lus- 
trous, and always presents a triangular reflection of light, the apex of 
which is at the lower extremity of the mallet-handle. This luminous 



EXAMINATION" OF PATIENTS. 



345 



triangle extends downward and forward toward the periphery of the 
anteroinferior quadrant of the membrane. The long leg of the anvil 
can often be seen extending downward and backward to articulate 
with the stirrup, the posterior leg of which is sometimes visible 
running upward and backward, both together forming a Y-shaped 
figure posteriorly to the upper portion of the hammer-handle. Ex- 
tending from the short process of the mallet, which is a yellow, 
dot-like projection of the upper end of the handle, are two nearly 
horizontal folds stretching forward and backward to the peripheral 
attachment of the membrane and separating the tense lower section 



s ms s 




Fig. 118. — Outer Surface of the Left Tympanic Membrane of an Adult, 
Enlarged Three and One-half Times. (After Politzer.) v, Segment of the 
tympanic membrane lying in front of the handle of the malleus, h, Pos- 
terior segment of the tympanic membrane, s, s, Prussak's striae, passing 
from the short process of the malleus to the spina tymp. post, et minor. 
ms, Membrana Shrapnelli. 

from the membrana flaccida, or ShrapnelPs membrane, above (Fig. 
118 and Plate VIII). 

For convenience of description the drumhead is divided into 
four sections by a projection of the axis of the handle of the mallet 
to intersect the circumference of the membrane above and below and 
a horizontal line intersecting the drumhead at its centre. The 
four segments into which the drumhead is divided by these inter- 
secting lines are called the anterior-superior, anterior-inferior, pos- 
terior-superior, and posterior-inferior quadrants, for convenience of 
description. 

Diseased appearances are described in their proper chapters. 



346 tests foe hearing. 

Tests for Hearing. 

It is difficult ordinarily to test the hearing of one ear in such a 
manner as to exclude entirely the perception of the test by the other, 
except in the employment of very delicate sounds, like the ticking of 
a watch. Even this ticking may be heard by the opposite ear when 
it is normal. The watch-sounds are the most constant in intensity, 
the most convenient at hand, and therefore the most universally used. 
The same side of the same watch should always be employed, since 
the variations in pitch and volume are great in different watches, and 
there is sometimes considerable difference in the loudness of the 
sounds emitted from the opposite sides of the same watch. Many 
tests should be made with adult persons of normal hearing to fix the 
average hearing-distance for any test-watch. This distance usually 
varies from 30 to 60 inches (76 to 152 centimetres), and determines 
the denominator of the fraction that expresses the hearing-power of 
any tested ear. The number of inches or centimetres at which the 
watch is heard gives the numerator. For example: A patient hears 
my 30-inch (76 centimetres) watch only 10 inches (25 centimetres) 
with his right ear and only 6 inches (15 centimetres) with his left. 
We record the watch-test as follows: H. D. R., 10 / 30 ( 25 / 76 ): H. D. L., 
V30 ("Ae)* which reads: Hearing-distance for right ear is 10 / 30 , or 
1 / 3 of the normal; for the left ear, 6 / 30 or 1 / 5 of the normal distance. 

During the test the patient must keep his eyes closed, to elimi- 
nate the element of imagination. The watch should always be 
brought slowly from a distance toward the ear until the patient indi- 
cates that he distinctly hears the sound. This process needs to be re- 
peated several times until it is demonstrated beyond doubt that he 
perceives the sound at the same point repeatedly. While testing an 
ear the opposite one should be kept closed, unless it is impossible for 
it to perceive the test. 

If the watch is not heard by bone-conduction it is brought into 
contact with the auricle, and if heard there the hearing is expressed 
as follows: JL (y C g), meaning contact for the watch. If not heard 
until pressed against the mouth of the meatus, it is recorded thus: 
^L. (-J0, — pressure for the watch. In case the watch cannot be heard 
at all it is written: %o (Vie)- I n y° un g persons it can be heard by 
bone-conduction in contact with the mastoid, process, upper teeth, 
forehead, etc., but it is not likely to be perceived from these points of 
contact by persons over 40 years of age. Great patience is required 



TESTS FOR HEARING. 



347 



in testing children's hearing, for they quickly answer in the affirma- 
tive whether they hear the test-sound or not, especially when they 
can see the source of sound. 

Tuning-forks are necessary in making a differential diagnosis 
between diseases of the transmitting and of the receiving apparatus, 
and in cases where the watch-sounds are not heard. If but one fork 
is used it is better to employ one of 512 vibrations per second, — ^the 
universal standard of pitch. This is C one octave above middle C of 
the piano. It gives off fewer overtones, or harmonics, if the ends are 
rounded than if square, and if the vibrations are caused by an auto- 
matic hammer attachment (Fig. 119), producing a moderate and un- 
varying blow. Some are made with sliding clamps to prevent over- 
tones and to raise and low r er the pitch. 

The fork-test is made by air-conduction similarly to the watch- 
test, For bone-conduction it is placed with the end of the handle 
resting on the mastoid, vertex, upper teeth, or forehead, with the 




Fig. 119. — The Author's Automatic Tuning-fork. 

shaft at a right angle to the bone-surface. The distance is recorded 
in terms of inches or metres, and the duration of the perception of 
sound is taken in seconds. Knowing the average distance and dura- 
tion for a given fork, the amount of loss or gain in the hearing-power 
can be quite accurately recorded. Hartmann's set of five forks (Fig. 
120) are tuned to 128, 256, 512, 1024, and 2048 vibrations per second. 
They are the C's of four octaves upward, beginning at the C below 
middle C of the piano. In the fork-test especial care must be exer- 
cised to ascertain that -the patient distinguishes between the musical 
note and the mere concussion or tactile perception of the unmusical 
vibrations. The latter can be perceived by the fingers as well as by 
the skull. The percussion-stroke must also be distinguished against. 
The fork must not be held with an edge of its branches opposite 
the meatus; and it should not be brought to the meatus from before 
backward or from above downward, otherwise the interference of 
sound-waves in those positions extinguishes the sound. 



348 



TESTS FOR HEARING. 



In making a differential diagnosis between diseases of the con- 
ducting mechanism and affections of the perceptive apparatus, the 
labyrinth, or nervous centres, the following tests are employed: — 

Schwabach's Test. — The most important use to which the 
tuning-forks are put is in making a differential diagnosis between 
diseases of the conducting, and of the perceptive, apparatus. In case 
there is an obstruction to the conduction of sound-vibrations through 



2048 



Ca 




Fig. 120. — Hartmann's Tuning-forks. 

the external auditory canal, or through the middle ear, to the healthy 
internal ear, it was discovered by Schwabach that a fork vibrating in 
contact with the cranial bones was heard longer in the affected ear 
than in the normal ear. The opposite is true when the auditory nerve 
is diseased; the fork then is heard longer by a normal ear. 

If the examiner have normal ears, he compares the patient's per- 
ception of sound with his own; or he may compare the perceptions 
of the patient with the average tests of his standard fork as ascer- 



TESTS FOR HEARING. 349 

tained with normal ears. By this means the increased or diminished 
length of time that the patient perceives the musical sounds can be 
accurately obtained and recorded. For example: The fork is struck 
and placed quickly upon the patient's mastoid process; the patient 
indicates the instant that he ceases to perceive the sound; immedi- 
ately the examiner brings the fork in contact with his own mastoid 
and notes whether he hears the vibrations after the patient fails to 
hear them. If so, labyrinfhal disease is indicated. If he does not, 
he sounds the fork again and places it upon his own mastoid process; 
the instant the examiner ceases to perceive the sound he places the 
fork in contact with the patient's mastoid. If the latter hears the 
fork then, after the examiner's normal ear ceases to hear it, an ob- 
struction to the conduction of sound, but not a disease of the auditory 
nerve, is indicated. 

The examiner notes, also, the number of seconds the patient's 
perception lasts. There are elements of uncertainty and error in this 
test, for in elderly persons bone-conduction is poor, and when one ear 
is normal, or when both are unequally affected, the better ear will per- 
ceive the sounds and cause confusion. 

Rinne's Test. — Air-conduction is superior to bone-conduction 
normally. The fork is heard before the meatus twice as long as on 
the mastoid. When the vibrations cease to be heard on the bone, if 
the fork, yet vibrating, is brought to the mouth of the meatus, it will 
again be heard by the normal ear (positive Einne). If the fork is 
heard longer by bone-conduction (negative Einne), there is trouble 
in the canal or middle ear. If the hearing is impaired equally for 
air- and bone- conduction, there is labyrinthal trouble. Lesion of 
the transmitting apparatus is shown by (1) gradual loss of perception 
of both lowest and highest notes; (2) by bone-conduction becoming 
relatively better than air-conduction. Labyrinthal disease is char- 
acterized by (1) no alteration in the relative acuteness of perception 
of sound by air and bone, both being diminished; (2) by deafness for 
some tones, generally the higher. 

Weber's Test. — In normal ears the fork is heard better when in 
contact with the skull if the auditory canals are closed. If one ear is 
closed by the finger the sound is intensified. This phenomenon is 
probably due to increased resonance of an inclosed space and ob- 
struction to the exit of sound-waves. This has been observed in 
adhesions, when the middle ear contained fluids, and when the drum- 
head was relaxed, without closing the mouth of the meatus. 



350 TESTS FOR HEARING. 

Bing's Test. — After the sound of the tuning-fork vibrating on 
the median line of the vertex or forehead ceases to he heard, if the 
external canal is then closed by the finger the sound will be again 
perceived for a time by the normal ear. If this time is too brief, it 
indicates trouble in the transmitting apparatus. If this interval of 
secondary perception is normal, an existing ear disease must be re- 
ferred to the labyrinth or nervous centres. 

Gelle's Test. — The mobility of the stirrup may be determined 
by condensing the air in the external meatus while the tuning-fork 
is vibrating on the head. If the stirrup is movable the sound of the 
fork is heard less distinctly or not at all during condensation, and 
dizziness or severe vertigo may result. The condensation of the air 
may be produced by the pneumatic otoscope (Fig. 114) or by a rubber 
bag with an olive-shaped nozzle. 

Galton's Whistle. — This is useful in determining the loss of per- 
ception for the highest notes in cases of bilateral ear diseases. If 




Fig. 121.— Galton's Whistle. 

one ear is affected but little or not at all, the whistle-sounds can 
scarcely be excluded from it. This instrument (Fig. 121) has a com- 
pass of about three of the highest octaves, and it is blown by means 
of a small rubber bulb. The tones can be varied by shortening or 
lengthening the cylinder by a screw mechanism. 

Politzer's Acoumeter. — This is an instrument of precision, which 
can be heard at a distance of forty-nine feet (fifteen metres) by the 
normal ear (Fig. 122). It is used very much like the watch directly 
opposite the opening of the canal, and the hearing-distances are re- 
corded similarly to those of the watch. It is held by the thumb and 
index finger resting in the semicircular plates, the thumb below, 
while the percussion-hammer is struck with the second finger. The 
cylinder which it strikes is tuned to C. To test bone-conduction 
the metal disc projecting from the perpendicular column is placed 
in contact with the mastoid process or the temple, while the meatuses 



TESTS FOR HEARING. 351 

are closed. I have observed that in sclerosis a patient may not be able 
to hear the acoumeter by air-conduction, although he may hear all of 
Hartmamr's forks. 

Speech-test. — This would be the ideal test were it not that no 
two voices are of the same pitch, volume, and timbre or quality. 
Indeed, the same voice may vary greatly at different times, and even 
at the same examination. Yet an excellent idea of the amount of 
usefulness still retained by the organ of hearing can be demon- 
strated by the speech-test. It is customary to choose words varying 
greatly in the relative preponderance of vowel and consonant sounds, 
such as the names of different cities and States, and to request the 
patient to repeat these words after the examiner. In order to elim- 
inate the possibility of lip-reading the patient is required to keep his 
eyes closed during the examination. Since there is a tendency to use 




Fig. 122. — Politzer's Aeoumeter. 

the same names repeatedly, in which case patients may introduce the 
uncertain element of guessing, it is better to employ numerals. This 
gives a much wider range of sounds and lessens the chance of repeat- 
ing the same sounds in the same order. Whispered speech is also 
used in addition to the low and loud tones. In advanced sclerosis and 
labyrinthal affections whispered speech cannot be interpreted. 

Vowels are heard much farther than consonants, but both should 
be used in the examination. The test should be made with each ear 
separately while the opposite one is kept closed. In unilateral deaf- 
ness a test should be made with both ears sealed with the moist fin- 
gers; if then the sound is heard as well as before, it is demonstrated 
that the sound was perceived by the normal ear. 

Music is heard much better than speech. Many persons with 
greatly impaired hearing, unable to understand a lecture or sermon 
or the drama, can derive pleasure from an orchestra or opera. 



352 



RECORDING CASES. 



A record of every case ought to be kept in a special form for that 
purpose. The following one has proven of great practical value in the 
writer's work: — 

S. S. Bishop's Case-record. 



Name 


Date 




Eesidence 


Occupation 




Age Sex 


Complaint 


Cause 


How long affected 


Heredity 





Colds 
Influenza 
Hay fever 
Nose-bleeding 
Sense of smell 
Snoring 
Sore throat 
Diphtheria 
Scarlet fever 



Measles 

Typhoid 

Scrofula 

Rheumatism 

Neuralgia 

Lues 

Brain disease 

Cough 

Spitting blood 



Hoarseness 

Pain 

Headache 

Night-sweats 

Dizziness 

Breath 

Alcohol 

Tobacco 

Narcotics 



Remarks 


Discharge from ear 


Subjective noises 


Eustachian tubes 


Mastoid disease 


Rinne test 


Weber test 


Bing 


Gelle 


Schwabach 


Automatic fork 


Diagnosis 


Prognosis 



Treatment 



Referred by 



Fees 



BECOBDING CASES. 



353 



. Case-record. 



Tests for Hearing. 



RIGHT EAR. 



LEFT EAR. 



Date. 



C 

128 



C 1 

256 



C 2 
512 



C 3 4 
1024 2048 



Acou- 
me- 
ter. 



Gal- 
ton. 



Watch. 



Date. 



C 

128 



C 1 
256 



C 3 
512 



C 

1024 



C 

2048 



Acou- 
me- 
ter 



ton." ™**- 



R 






23 



354 



RECORDING CASES. 



Case-record. 

RIGHT. LEFT. 



! \ 



/ / 



V 






\) 



Diagnosis, etc. 



Diagnosis, etc. 



RECORDING CASES. 355 

Case-record. 

History and Treatment. 



Diagnosis, etc. 



t\-\ 



I I 

; / 

/ 



Diagnosis, etc. 



CHAPTER XXX. 

COMPRESSED-AIR APPLIANCES AND THEIR USES. 

By a series of experiments with the compressed-air gauge the 
author has found that the maximum amount of pressure that can be 
obtained with a Politzer air-balloon of the capacity of eight fluid- 
ounces is 6 pounds; with the six-ounce bag the pressure may be 
made to reach 10 or 12 pounds. The difference in favor of the 
smaller bulb represents the greater advantage one has in grasping 
a small object. This amount was the maximum obtainable by an 
unusually strong hand, accustomed for years to compressing airbags 
handled at the greatest advantage for leverage, — that is, with the 
larger end of the balloon between the thumb and strongest fingers, 
and the tapering end under the third and fourth, or weakest fingers. 
As the reverse method is practiced by many aurists, much less force 
than 6 and 10 pounds must result. 

Ten- and twelve- ounce bags are manipulated in Vienna by 
pressing them against the operator's side, but they are not much 
used in America. The Gruber balloons, with the opening or air-valve 
at the larger end, might possibly accumulate more force than we have 
mentioned, by repeatedly compressing them, but, on account of the 
valves being imperfect or soon becoming useless, we have discon- 
tinued their use. Professor Gruber himself preferred the bulb having 
a perforation in the end to be covered and compressed with the thumb. 
Experiments have not been made with this kind, for one could not 
be found. 

The rubber bulb usually supplied by the Davidson Company for 
hand-sprays and inflators can be made to exert 15 or even 18 pounds, 
but not by a single compression. However, it is not practicable to 
employ more than 15 pounds with the 3 / 16 -inch rubber tubing ordi- 
narily supplied with inflators. A higher pressure distends it, and 18 
pounds will rupture it with a loud report. The thick, firm, white 
tubes accompanying the De Vilbiss atomizers will stand more, for 
I have tested them with 45 pounds' pressure without even distending 
them. 

(356) 






COMPRESSED-AIR APPLIANCES AND THEIR USES. 



357 



The force necessary for spraying the nose and throat is not great. 
Eight pounds will project continuous sprays of watery solutions or 
lavolin with sufficient force from the Davidson atomizer. About 12 
pounds' pressure is needed to produce a continuous and copious 
lavolin-spray from the De Vilbiss atomizer, and it requires from 30 
to 40 pounds to throw a spray of unheated glycerole of tannin. 

In adapting the improved compressed-air apparatus to the treat- 
ment of the ear the author endeavored to devise some means of 
determining and controlling the force and volume of air, or the 




Fig. 123. — The Author's Original Compressed-air Meter. 

dosage. As the illustration above (Fig. 123) will show, this has been 
accomplished by placing a pressure-gauge between two valves on the 
escape-tube of the air-receiver. This arrangement utilizes the gauge 
for registering not only the air-pressure in the reservoir, but also the 
force of the current of air while it is escaping at the cut-off of the 
treatment-tube. The cut-off that has proven most satisfactory is a 
modification of the Davidson instrument, to which the writer has 
added a controlling thumb-screw to hold it continuously open, when 
desired, to any given extent (Fig. 124). . 



358 



COMPRESSED-AIR APPLIANCES AND THEIR USES. 



The meter is used as follows: By opening the outer, right-hand 
valve marked 1, by turning the wheel to the left one-fourth of its 
circumference, pressing the thumb-valve of the cut-off, and opening 
Valve 2, gradually you may obtain any number of pounds' pressure 
desired at the cut-off, — from 1 up to the full amount of pressure in 
the reservoir. To use 10 pounds : with the cut-off and Valve 1 open, 
turn Valve 2 until the index needle runs up to 10. As long as 
the cut-off remains open, the needle indicates 10 pounds. If you 
close the cut-off the needle rises to indicate the whole number of 
pounds in the reservoir. Now, if you fit a spray-producer to the cut- 
off and open it, the first impulse of the column of air, which is small 
in volume, is expended in filling the atomizer and starting the spray. 
In using the nasal bulb of the inflator (Fig. 134) for treating the ear 




Fig. 124.— The Author's Cut-off. 



the first impulse is expended in filling the nasal and superior pharyn- 
geal cavities in addition to inflating the middle ear. The volume of 
air is so small that the needle drops down to 10 at once and remains 
there as long as the cut-off is kept open. If no more than this amount 
is desired the cut-off should be opened before the current is turned 
on and Valve 2 should be slowly opened until the needle indicates 
the number of pounds required. No greater pressure will then be 
exerted unless the cut-off valve is closed. 

When it is desired to interrupt the air-current for the purpose 
of producing movements of the membrana tympani and ossicles, or 
to throw jets of volatilized medicine or sprays into the tympanic 
cavity, it is a simple matter to control the pressure in this way. Let 
us assume that we want to use, with the nasal-tipped inflator adapted 
to this purpose, 2 atmospheres, or about 30 pounds. Valve 1 being 



COMPRESSED-AIR APPLIANCES AND THEIR USES. 359 

opened, apply the cut-off to the nasal bnlb containing the medicine 
on sponges; open the cut-off; turn on 10 pounds with Wheel 2 and 
then close the cut-off. The needle rises. Now, if the inflator is in- 
serted into the nostril with the patient's nose firmly closed and 
cheeks fully distended, the instant the cut-off is opened the needle 
runs down to 10. Close the cut-off and the needle mounts to 30 
pounds. Open the cut-off at that moment and the needle descends 
again to 10; close the cut-off and the needle rises; the instant it 
touches the 30 pounds' mark open the cut-off again and so on; re- 
peatedly opening and closing the cut-off will give repeated impulses 
at any given pressure below that in the reservoir. 

The resistance offered by the sponges is small, — less than one- 
third of an atmosphere. 

A little practice will enable anyone to measure the doses skill- 
fully and to give effective treatments without fatigue. 

If very rapid interruptions are required, Valve 2 should be opened 
more freely than in the example given. For 30 pounds' maximum 
pressure about 20 pounds should be allowed for the uninterrupted 
current. Experience with this method indicates that not more than 
60 interruptions per minute should be made in order to produce per- 
ceptible vibratory movements of the drumhead and ossicles. 

The dose of air for ear treatment varies greatly in different in- 
dividuals. While 15 pounds might endanger the continuity of an 
infant's drumhead or one greatly weakened by disease, or the thin 
cicatricial membranes closing old perforations, I have often applied 
60 or more pounds to old, thickened, and hardened drumheads with- 
out rupturing them. 

It is evident that, if it require 40 pounds in some cases to propel 
sprays into the middle ear, it follows that in such instances rubber 
airbags are insufficient, for they do not average more than from 6 to 15 
pounds. But with high pressure only a small volume should be used. 
I would propose the following rule to keep the operator within the 
limits of safety: The higher the pressure, the lower the volume 
should be. If the density of the air- is greater than one wishes to 
use, even with a minute volume, it is easy to avoid the high pressure 
when using the nasal-tipped inflator by leaving the opposite nostril 
open during the first impulse until the needle descends to the proper 
point. This allows the surplus air to escape by the opposite nostril. 
The same purpose is accomplished with the catheter by holding the 
catheter-tipped inflator (Fig. 123) a little withdrawn from the mouth 



360 COMPRESSED-AIR APPLIANCES AND THEIR USES. 

of the catheter while the cut-off is first slowly opened. The surplus 
pressure then escapes at the junction of the inflator and catheter. 

The volume should be proportioned to the density with care in 
cases of atrophied soft palate, so as not to strain the muscles of the 
throat by too powerful inflations, especially if they are subject to 
rheumatic sore throat. 

It serves a convenient purpose to instruct patients to raise one 
or both hands every time they feel one or both ears inflated. This 
obviates the necessity of frequently using the auscultating tube. 

The warnings against the danger of rupturing the membrana 
tympani by politzerization have been freely sounded. The author 
has never ruptured a drumhead by compressed air, while he has 
seen a considerable number that were torn or perforated by blows 
on the ear. Even in men employed in caissons of tunnels, bridges, 
etc., where they are compelled to work in an atmosphere condensed 
under a pressure of from 40 to 60 pounds, it is rare to find a ruptured 
drumhead. This may be due to the fact that they are instructed 
to inflate the ears so as to equalize the pressure on both sides of the 
membrane. In this connection it must not be forgotten that there 
is always the natural atmospheric pressure of nearly 15 pounds on 
the outer surface of the drum. Notwithstanding this, an eminent 
otologist has asserted that drumheads have been lacerated by Polit- 
zer's method. 

Professor Politzer says: "During thirteen years only fourteen 
cases of ruptured drumheads are known. In the case of a normal 
membrana tympani a pressure of 45 to 60 pounds is required to cause 
rupture. In treatment, however, we apply only a pressure of about 8 
pounds." If there were any fear of rupture, it could probably be pre- 
vented by firmly pressing the tragus into the external meatus. 

As compared with the Valsalvan method of autoinflation, the ap- 
plication of medicated nasal-tipped inflators as I have adapted them 
to the compressed-air apparatus makes an effective topical applica- 
tion of various medicaments possible without any active exertion on 
the part of the patient. In the Valsalvan experiment there is no 
medication of the middle ears, but simply a mechanical effect of 
moderate pressure and a probable congestion resulting from the strain- 
ing effort. A. Hartman has shown that from 4 to 8 pounds* pressure 
by the Valsalvan method is required to bulge forward a healthy 
drumhead. In numerous experiments the pressure averaged from 
20 to 26 pounds in males and from 14 to 22 in females; but owing 






COMPRESSED-AIR APPLIANCES AND THEIR USES. 361 

to swelling of the Eustachian tube or contained secretions this experi- 
ment often fails. 

The unwisdom of advising patients to practice the Valsalvan 
experiment has often been demonstrated by individuals who have 
come under my observation with a history of rapid failure of hearing 
owing to their habit of carrying the aurist's instructions to excess. 

Politzer's method is far preferable. He says: "The pressure for 
the application of my method in practice varies, as a rule, between 
15 and 60 pounds." 

A decided advantage to both patient and operator, in the adapta- 
tion of the infLator to the compressed-air apparatus, lies in the fact 
that it renders it possible to treat many aural patients without the 
Eustachian catheter. 

The sponges of the inflator may be saturated with solutions of 
various remedies, and sprays of these medicines can be propelled 
through the nose and Eustachian tubes into the middle ears with 
ease and certainty in the majority of cases. This diminishes the 
danger of syphilitic infection and of irritation of the Eustachian 
orifices by the catheter. 

Gentle pressure will often accomplish this. Indeed, patients 
sometimes feel a spray enter the ear from an ordinary hand-atomizer, 
especially when the cheeks are distended. By turning on the current 
of air gently and gradually increasing it, the permeability of the tube 
may be re-established by a weak air-pressure more easily than by a 
sudden, forcible current. 

In practicing this method we have usually found the results most 
satisfactory when the patient assisted by inflating the cheeks and 
keeping the lips firmly closed. At the instant the closed nasal cavities 
become filled from the inflator the velum palati and base of the 
tongue press automatically upward and backward, completely closing 
the post-nasal space. 

When the effort to inflate the middle ears with air or lavolin jets 
alone fails, it can be made to succeed by placing from 6 to 10 drops of 
sulphuric ether on the sponges in the inflator. The instant the ether 
enters the ears there is a decided sensation of coolness, followed by a 
glow of warmth. The stimulating effect can be seen also in the in- 
jected condition of the malleal plexus of vessels soon after the treat- 
ment. There are many instances in which the ears are more readily 
inflated during the act of swallowing. 

It has been suggested that these forcible air-currents might con- 



362 COMPRESSED-AIR APPLIANCES AND THEIR USES. 

vey discharges into trie mastoid cells, but Michael has "proved that, 
especially with the application of strong currents of air, the secretion 
in the tympanic cavity is always propelled into the external meatus 
and not into the mastoid process." 

Occasionally one sees a case in which the current of air from 
the nasal-tipped inflator fails to open the Eustachian tube. Probably 
the anterior lip of the orifice of the tube is pressed by the air more 
firmly than ever against its fellow, closing it like a valve. A case of 
tubal stenosis resisted 90 pounds with the nasal bulb, but 50 pounds' 
pressure carried a spray into his middle ears through the catheter. 

Treatment by the catheter is accomplished with the inflators al- 
ready mentioned, the catheter-tip being substituted for the nasal 
bulb. The sprays are thrown through the catheter in interrupted 
jets without imparting painful movements to the catheter, which is 
well-nigh impossible in the practice of inflation with the airbag 
fitted with the hard-rubber tube which is inserted directly into the 
catheter, and without any intervening flexible tube, as the practice 
is in Vienna. 

Proper precaution should be taken to prevent dust from enter- 
ing the air-reservoir, although by the author's methods all air enter- 
ing the ears is filtered and medicated. 

Finally, these methods make the middle ears nearly as accessible 
as the nose and throat for treatment with the various volatile remedies 
and sprays. 



CHAPTER XXXI. 

METHODS OF PRODUCING AND USING COMPRESSED AIR. 

For a considerable time the author has been using a convenient 
instrument called a vaporizer in connection with the compressed-air 
receiver, and the results have been so satisfactory that he has intro- 
duced it into all of his clinics. This instrument and process of admin- 
istering aeriform fluids, although used by a few physicians since 1888, 
appear to be too little employed. 

The vaporizer (Fig. 125) is not only different in construction, but 
also in operation, from the various kinds of spray-producers or nebu- 
lizing inhalers. The atomized product projected by it is not properly 
a spray or a vapor until it expands in the open air. It is so finely 
comminuted, indeed, that before it leaves the glass container the eye 
cannot discern it. After its exit from the nozzle it expands into a 
beautiful floating mass that is comparable to the most delicate undu- 
lating cloud. This fine nebula, which is produced and retained until 
administered under a higher pressure than hand-bulbs afford, may 
be impregnated with volatile or non-volatile medicaments. 

While making some experiments with the vaporizer I discovered 
that medicines three or four times stronger than patients would 
tolerate from the ordinary atomizers could be thrown into the re- 
spiratory passages, and even into the middle ear, without evoking any 
disagreeable symptoms. Xo less pressure than 20 pounds or even 
more should be employed in order to propel the nebula in sufficient 
volume and with enough force to dislodge tenacious secretions or 
crusts, to impress the nebulized remedies on the diseased surfaces, 
and to dilate the Eustachian tubes, innate the middle ears, or to open 
up stenosed bronchioles and occluded air-cells. While a pressure of 
20 pounds may be sufficient, no injury has followed the employment 
of a much higher pressure, as the excess escapes from the lips. 

The combined pump and receiver is a very practical, durable, 
and economical form of apparatus where the pumping must be done 
by hand, it being comparatively easy to obtain 50 pounds. It is pro- 
vided with a regulating meter-valve for controlling the pressure by 
the method described in a paper read by the author before the section 

(363) 



364 



METHODS OF PRODUCING AND USING COMPRESSED AIR. 



on Otology and Laryngology of the American Medical Association at 
Detroit in 1892. Any spray-producer or innator can be attached to 
the cut-off and employed in the usual manner. By attaching the 
writer's improved cut-off (Fig. 124) to the Globe nebulizer (Fig. 14) 
and opening the cut-off with the thumb-screw the instrument will op- 
erate automatically for a patient to take an inhalation, while the phy- 
sician is engaged in treating others. 




Fig. 125. — Vaporizers and Combined Air-reservoir and Hand-pump. 

Ear Treatment. 

The vaporizer can sometimes be substituted for my improved 
middle-ear inflator for projecting medicaments into the ear. With 
the latter we- never use a stronger solution of the camphor-menthol 
than 3 per cent., while with the vaporizer we medicate the tympanic 
cavity with the 10-per-eent. solution in lavolin without any un- 
pleasant results. 



METHODS OF PRODUCING AND USING COMPRESSED AIR. 



565 



The nozzle is fitted into one nostril, while the other is held 
tightly closed, as in politzerization. The cheeks are fully distended 
with air, and the current is turned on from the compressed-air reser- 
voir. The instant the nebula is felt to enter the ear the patient, 
should raise his hand. Then the' current is repeatedly interrupted 
by the cut-off so as to alternately fill the middle ear with the nebula 
and allow it to escape. This produces not only inflation of the tube 
and tympanum and motion in the ossicles and drumhead, but it 
medicates their mucous lining, on the same principle that we observe 




Fig. 126.— Compound Hydraulic Pump Beneath the Water-basin. 

in medicating the mucous membrane of the eye, or the nose, or 
throat, when it is diseased. This, combined with the aid of the mas- 
sage otoscope, provides an ideal treatment for chronic catarrh of the 

tympanic cavity. 

When we reflect that middle-ear diseases are largely consequent 
npon an inflammatory action in the nose or throat, it becomes 
apparent how necessary it is to employ a thorough medicinal as 
well as mechanical treatment addressed to this section of the respira- 
tory system; otherwise we cannot hope to effect a permanent im- 
provement. 



366 



METHODS OF PRODUCING AND USING COMPRESSED AIR. 



In connection with the use of compressed air the question of 
air-pumps is an important one. In a city with waterworks the com- 
pound hydraulic pump (Fig. 126) is effective, since it gives about dou- 
ble the amount of pressure obtained by the single-acting pump (Fig. 
127). It requires to be cleaned and repaired occasionally, or it fails 
to afford the required pressure. The maximum of pressure to be had 
on a ground floor in Chicago, with a compound hydraulic pump, aver- 




Fig. 127. — Single-acting Hydraulic Pump. 

ages from 45 to 55 pounds, — an amount sufficient ordinarily for the 
aurist, for the air is constantly replenished. In the great modern 
office buildings, compressed air is supplied to the tenants by moans 
of Westinghonse electric pumps, which are capable of affording any 
desirable pressure and quantity. In the country the surgeon must 
be satisfied with the hand-pumps (Figs. L28 and 129), unless he pro- 
vides an elevated water-reservoir with sufficient head to furnish the 



METHODS OF PRODUCING AND USING COMPRESSED AIR. 



367 



pressure. The combined hand-pump and reservoir made by the Owens 
Brass and Copper Works, of Chicago, is very convenient (Fig. 125). 
The pump is contained within the reservoir, which is supplied with an 
air-gauge, treatment-tube, and cut-off. The whole outfit weighs only 
fourteen pounds, which makes it conveniently portable. 

Another efficient apparatus is manufactured by the Cleveland 
Faucet Company. It is supplied with a modification of the authors 
air-meter that registers very accurately the pressure at the will of the 




Fig. 128. — Rotary Air-pump. 



operator and keeps it uniformly at any given pressure for which it 
is set (Fig. 130). Below 30 pounds it operates to a nicety. Pressure 
above this point can be used nearly to the amount contained in the 
reservoir, but not with an .equal accuracy of regulation. Another 
excellent modification of the Bishop air-regulator is made by the 
Globe Nebulizer Company (Fig. 1). In offices and clinic-rooms that 
are supplied with compressed air from a distant reservoir, the im- 
proved meters or regulators can be attached directly to the air-tubes 
in or upon the walls. In this case it is not necessary for each room 



368 POLITZERIZATION. 

to have a separate air-tank, for the the amount of pressure at the 
cut-off is controlled with facility, even when the pressure in the com- 
mon reservoir is maintained at three or four atmospheres. Eegarding 
all of these apparatus the author speaks from experience in their use. 
Politzerization. — The aurist who is not provided with a com- 
pressed-air apparatus should possess a Politzer airbag, and it is well 
to have one at hand to take the place of the air-pump should it fail 
to work. The Politzer bag (Fig. 133) is fitted with a nasal tip joined 




Fig. 129. — Globe Double-cylinder Air-pump. 

to the bag by eight inches of soft-rubber tube. One should also have, 
a Buttle inflator (Fig. 132) fitted with both nasal and catheter tips. 
In manipulating these the same rule should be observed as in the 
use of the author's compressed-air inflator (Fig. 134). The axis of 
the nasal bulb should be parallel to the plane of the floor of the 
nose. The object is to throw the column of air in the direction of 
the Eustachian orifice — not toward the nasal duct, through which 
the air is sometimes forced, nor toward the frontal sinus. The Polit- 
zer bag should be grasped with the larger end between the thumb 
and stronger fingers, so as to be able to exeri the greatest force when 
it is necessary. The rubber tube intervening- between the nasal or 



CATHETEKIZATIOtf. 



369 



catheter tip and the bag does not transmit the motion imparted to the 
bag by the hand and prevents painful jerkings of the tips and the 
catheter. Especially in the use of the catheter this is an important 
matter, and may prevent not only injury to the nose, but irritation or 
contusion of the Eustachian tube. The six- or eight- ounce bags are 
preferable to the larger sizes. The eight-ounce bag is the most useful 
for all purposes, and the rubber should be fresh, soft, and of the 
finest quality. 




Fig. 130. — Air-meter of Improved Pattern. 



Catheterization. — The soft-silver catheters are the best (Fig. 
135). They can be easily bent to accommodate any irregularities in 
the nasal passages or in the vicinity of the Eustachian tubes. There 
are German-silver catheters in our markets, but Albert H. Buck is 
very correctly opposed to their use, since they are far inferior to the 
pure-silver or hard-rubber catheters. It is desirable to have three 
sizes. As large a calibre as can be introduced without causing discom- 
fort should be employed. To introduce the catheter, the beak of the 
instrument is placed on the floor of the nose just posteriorly to the 
skin-lined fossa at the entrance of the naris. At the first step, the 
handle is depressed so that the convexity of the beak will not hurt the 



370 



CATHETERIZATION. 



arch of the nasal opening, but as soon as the beak rests on the floor 
the handle is raised and at the same time carried onward, bringing the 
main axis of the catheter to a parallel with the floor. As the instru- 
ment enters the nose it must not be forgotten that the patient invol- 




Fig. 131. — Globe Compressed-air Apparatus. 

untarily moves his head backward. As soon as the beak touches the 
posterior wall of the pharynx we withdraw the catheter about one- 
eighth of an inch, rotate it so as to turn the beak outward and slightly 
upward, and its extremity should now be opposite the orifice of the 




Fig. 132.— Buttle's Inflator. 



tube. Then the hand is carried a little toward the median line, so 
as to bring the beak into the tubal opening (Figs. 27 and 136). With 
practice one can determine when the catheter rests in the tube by 
the sense of fixation imparted to the instrument. During this ma- 
nipulation the ring on the proximal end of the catheter will indicate 



CATHETERIZATION. 



o rv-i 
O i 1 



the position of the concavity or the convexity of the distal extremity. 
No force need be used. In cases of certain deformities of the inferior 
turbinated bodies and of the septum the catheter must be rotated 
through forty-five or ninety degrees, or more, before it can reach the 




Fig. 133.— Politzer's Airbag. 

pharynx. With the head thrown backward the weight of the silver 
catheter is often sufficient to carry it into the pharynx. The intro- 
duction can be facilitated by elevating the tip of the nose with the 
thumb of the left hand while the fingers rest on the bridge of the 
nose or on the forehead. 




Fig. 134. — The Author's Improved Inflator. It is provided with a tip 
to fit into the Eustachian catheter. 



However, with the improved compressed-air appliances at hand 
it is not very often necessary to use the catheter except for sclerosis. 
It is destined to pass out of vogue to some extent, for the reason that 
air, volatile medicaments, and even fluid-vaselin sprays can be sue- 



372 



CATHETEKIZATION. 



cessfully projected into the middle ears by means of the improved 
inflator (Fig. 134) adapted to the compressed-air apparatus. To the 
average patient this is a happy culmination of the inventor's efforts, 




Eustachian Catheter. 



for it averts much discomfort, the possibility of infection and of irri- 
tative effects, and incidentally reduces the amount of skill required 
for treatment. It may be necessary to employ the catheter to inject 




Fig. 136.— Vertical Section of the Nasopharynx with the Catheter 
Introduced into the Eustachian Tube. (After Politzer.) a, Inferior tur- 
binated bone, b, Middle turbinated bone, c, Superior turbinated bone. 
d, Hard palate, e, Velum palati. f, Posterior pharyngeal wall, g, 
Rosenmuller's cavity, h, Posterior lip of the orifice of the Eustachian 
tube. The frontal sinuses are shown above the line c. 

liquids into the middle ear, or when the inflation must be limited to 
one ear, but even in the latter case we may generally accomplish this 



CATHETERIZATION. 



373 



end with the improved inflator by closing the opposite ear with the 
patient's finger during inflation. However, we do not desire to be 
understood as having discarded the rise of the catheter after many 
years of experience with it. In certain cases it is indispensable, but 




Fig. 137. — Fixation of the Catheter with the Left Hand. Catherization 
as it is practiced in Vienna. (After Politzer.) 

there can be no doubt that the injudicious and unskillful use of this 
instrument has often been productive of harmful results. 

When occasion necessitates the use of the catheter (Fig. 137), the 
air-pressure must be greatly reduced, for, as Huntington Eichards ob- 




Fig. 138. — Toynbee's Auscultation-tube. 



serves: "By it greater power is exerted, and it is more strictly limited 
to a single ear." If more than 1 or 2 atmospheres (15 to 30 pounds) 
be used with the catheter-beak not properly adjusted, there is a pos- 
sibility of forcing the air into the submucous tissues and producing 
a dangerous emphysema. We have never seen any such results from 



374 



AUSCULTATION OF THE EUSTACHIAN TUBE. 



this cause, but three deaths are recorded. Thomas Faith has re- 
cently reported to me a case of emphysema of such character, with 
recovery. 

An aid in both diagnosis and treatment lies in Toynbee's aus- 
cultation-tube (Fig. 138). One end of the tube should terminate in 
a white tip and the other in a black one. By inserting the white tip 
in. the operators ear while the black one rests snugly in the patient's 
meatus, any sound produced in the ear of the patient is perceived 
by the surgeon. Thus, when air is forced through the Eustachian 
tube and impinges against the inner surface of the membrana tym- 
pani, the resulting sound is conveyed along the continuous column 
of air in the patient's external canal, the rubber tube, and the sur- 
geon's auditory meatus to his drum. It is not difficult, then, to dis- 
tinguish between the free, breezy puff of air through a patulous 
Eustachian tube and the high-pitched, squeaking sound occasioned 
by a stenosis. 



CHAPTER XXXII. 
DISEASES OF THE EXTERNAL EAR. 

The Auricle. 

Theee are certain injuries and diseases of the auricle that are 
not properly classed as ear affections, the treatment of which is con- 
ducted on general principles sufficiently amplified in works on sur- 
gery. Such affections and injuries as would not require treatment 
differing from that demanded by the same conditions in other parts 
of the body will not greatly encumber our pages. 

diseases of the auricle. 

Frost-bite. — The s3^mptoms of this condition are so familiar that 
a description would be superfluous. The chief object to be accom- 
plished is to prevent a sudden disturbance of the circulation in the 
skin, by insuring a very gradual return to the normal temperature. 
This is best secured by the application of continuous cold by means 
of snow inclosed in a handkerchief or by an icebag (Fig. 194) to the 
auricle after padding the post-auricular space for support. As the 
crushed ice melts, the temperature of the bag gradually rises until 
the ice becomes water, and the temperature of the water slowly arrives 
at the normal bodily temperature. Then the auricle should be dressed 
with a thick covering of an ointment consisting of equal parts of 
benzoinated oxide-of-zinc and carbolic-acid ointments. The parts 
should be protected with gauze or absorbent cotton. 

Eczema. — This skin disease is so common and so well described 
in general works that we may best confine ourselves to the subject 
of treatment. Eczema is usually associated with a chronic suppura- 
tive inflammation of the middle ear, and is a result of that disease. 
The external canal is likely to be involved at the same time. The 
acrid, irritating discharges set up the dermatitis wherever they spread, 
even to the neck, side of the face, and head. So long as these dis- 
charges continue to bathe the skin, just so long will the treatment 
of the eczema prove unavailing. The ear must be so cleansed and 

(375) 



376 DISEASES OF THE AURICLE. 

kept free from pus, by constant vigilance and the treatment out- 
lined in the chapter on suppuration, that the discharges cease to 
reach the auricle and surrounding parts. If there are crusts, they 
are softened and removed by means of Castile soap and warm water. 
When the surface is thoroughly clean it is covered thickly with ben- 
zoinated oxide-of-zinc ointment, which must be strictly fresh and 
prepared with the purest zinc oxide. This is retained in place by a 
gauze or fine-linen dressing. In case of great itching or burning the 
carbolic-acid ointment is added to the zinc ointment in the propor- 
tion of one-fourth or one-half carbolic ointment. This acts not only 
as an antiseptic, but as a grateful local anaesthetic also. Among the 
most prompt and effective remedies to relieve the pruritus are resinol 
and epidermol. In obstinate cases a 3-per-cent. salicylic-acid oint- 
ment of lanolin has proven rapidly curative, and the same may be 
said of the yellow-oxide-of -mercury ointment, 5 grains to the ounce of 
vaselin (1 per cent.). 

When the raw-appearing surface rapidly exudes drops of serum, 
weeping eczema, it should be gently dried by merely touching with 
absorbent cotton without any friction, and then covered with aristoi 
or nosophen. Prompt drying and cicatrization follow. General treat- 
ment may be needed for an impoverished condition of the system, 
and, if so, Fowler's solution of arsenic is a valuable addition to in- 
ternal medication. 

Lupus. — Lupus vulgaris generally attacks the auricle second- 
arily to its existence in the face. Yet we have seen it confined to the 
auricle and external canal, following, like eczema, a chronic suppura- 
tion of the middle ear. Brown tubercles,, about the size of a pinhead 
or a small pea, form in the concha, about the mouth of the auditory 
canal, or in other parts of the auricle. They may be covered with 
brown crusts or scales. Sometimes they shrink up so as to form cica- 
trices, which, in turn, may break out later. Lupus exulcerans appears 
in the form of ulcers covered with brown crusts, underneath which 
is a spongy, moist, or bleeding surface. Nodules may be seen in the 
periphery of the ulcers and aid materially in making a certain diag- 
nosis. There is no considerable pain in the early stages, as a rule, 
nor intense itching as in eczema. The skin is of a darker hue than in 
the latter disease. A case in my practice, of a lawyer and prominent 
politician of 60 years, was secondary to a chronic suppuration of the 
middle ear. After stopping the suppuration the ulcers in the meatus 
and on the auricle healed under aristoi. After three years, however, 



DISEASES OF THE AUKICLE. 



377 



the disease again attacked the auricle, during a journey in the West, 
and destroyed it. (Since writing the above he has died.) 

All the diseased tissue is best removed by the curette, the gal- 
vanocautery, nitrate-of -silver stick, lactic acid, etc., under cocaine 
anaesthesia, and the wound is dressed with aristol or iodoform and cov- 
ered with dry iodoform gauze. The results of the x-ray treatment 
have been so favorable in a considerable number of cases that the 
patient should be given the benefit of a faithful trial of its efficacy. 




Fig. 139. — Gangrene of the Ear; Mastoid Operation. 



The prognosis must be guarded, on account of the strong tendency to 
recurrence. 

Gangrene. — Gangrene of the auricle is a very rare disease. It 
may arise without any assignable cause; but any condition that viti- 
ates the blood and lowers the vitality and powers of resistance in the 
presence of a local exciting cause, such as intense cold, pressure, acrid 
discharges, burns, destructive chemicals, etc., predisposes to this 
necrotic process. The author has seen one case only. This applied 
at his clinic at the Illinois Medical College with the following his- 



3 78 DISEASES OF THE AURICLE. 

tory: A boy, 2 years old, had been an inmate of an orphan-asylum 
five months. Two months before we saw him a suppuration of the 
right ear began. Five days before he was admitted to the hospital 
the skin covering the concha turned black and emitted a foul stench. 
Both sides of the auricle were necrotic, as well as the adjoining skin 
of the mastoid process. The necrotic tissue was cut away and the 
bone was found involved, necessitating a mastoid operation (Fig. 
139). After the operation the child, in common with other members 
of his family, had measles. His brother died, and our patient was 
attacked with pneumonia, from which he died. The autopsy showed 
pulmonary tuberculosis. 

If gangrene is seen early enough, warmth should be applied to 
stimulate the circulation until the necrotic tissue separates from the 
healthy; otherwise operative measures as indicated above are called 
for. 

Carcinoma. — This more frequently arises on the auricle or in 
the external meatus than in the middle ear or mastoid process. It 
begins with a sensation of irritation or itching, which the patient 
increases by persistent efforts to relieve. The development is slow at 
first and rapid afterward. The irritation is supplanted by ulceration, 
which, however, is easily distinguished from other similar conditions. 
While in the lupus exulcerans the ulcer is deep, excoriating, and 
penetrating, in carcinoma the ulcerating surface is raised above the 
surrounding tissues, exuberant granulations often projecting to a con- 
siderable degree. If the lateral cervical glands become infiltrated the 
diagnosis is more certain, but they are slow to participate. 

The ulceration may extend to the tympanic cavity, labyrinth, 
and cranial cavity, producing facial paralysis, haemorrhages, menin- 
gitis, brain-abscess, or thrombosis, and, after great suffering, death. 
The treatment consists in complete extirpation of the diseased tissue 
when possible, the knife penetrating beyond the disease into the sur- 
rounding healthy tissue. If the auricle is extensively involved it 
should be amputated, and if the cervical glands are affected they 
must be excised at the same time. Should it be necessary to invade 
the external meatus, a plastic operation may possibly preserve its 
patency, which is important on account of the hearing. After-treat- 
ment is the same as for lupus. For treatment with alcoholic injec- 
tions see treatment of carcinoma of the pharynx. 

Perichondritis. — This is not a frequent disease, but early treat- 
ment is important to prevent deformity. In the early stage there 



DISEASES OF THE AUKICLE. 379 

occurs a swelling of a part or the whole of the auricle, with a dusky- 
red surface, accompanied by heat and pain. We have seen the auricle 
increased to an enormous size by the effusion of a syrup-like fluid be- 
tween the cartilage and the perichondrium. 

Treatment consists first in the application of cold by means of 
an icebag (Fig. 194). If there is great swelling with fluctuation it 
must be incised, the fluid pressed out, and the cavity irrigated with 
antiseptic solutions. We have obtained the best results from inject- 
ing equal parts of tincture of iodine and water or alcohol, and apply- 
ing pressure with cotton and a bandage. 

Haematoma. — Othematoma is an effusion of blood between the 
cartilage and the perichondrium. It rarely arises spontaneously, but 
is generally the result of traumatism. It occurs suddenly after a blow 
on the ear or pulling the auricle. It is a rather frequent occurrence 
in the mentally defective, and possibly indicates a disease of the base 
of the brain. Brown-Sequard has shown that section of the resti- 
form body in animals is followed by this disease. The appearance 
of the tumor is accompanied by heat and pain. It nearly always oc- 
cupies the anterior aspect of the auricle, and may cover a large por- 
tion of that surface. The natural outlines are obliterated, and in 
their place is a fluctuating, pale, bulging tumor. It may rupture 
spontaneously or suppurate, or in rare instances it disappears. Dur- 
ing the first, or inflammatory, stage, when there are heat and pain, 
the constant application of cold is indicated (Fig. 194). If an icebag 
is not obtainable, a bladder can be filled with ice or snow as a sub- 
stitute. If the swelling does not diminish, it must be incised, in one 
of the natural folds to prevent disfiguration, and emptied of its con- 
tents. Most satisfactory results have followed washing out the cavity 
with a 5-per-cent. aqueous solution of carbolic acid, insufflating with 
aristol, and binding it with an absorbent-cotton compress. Randall 
opens the sac, curettes it, rubs with iodine glycerite, packs with iodo- 
form gauze, and covers it with a pressure bandage. 

In this connection it is our duty to condemn in the strongest 
terms the brutal practice of pulling and 'boxing the ears of children 
indulged in by ignorant parents and teachers. The author has seen 
many cases of deformities, ruptured drumheads, abscesses, and deaf- 
ness resulting from this inhuman habit. 

Cystoma. — Cystoma is a tumefaction usually found on the ante- 
rior aspect of the auricle. Its appearance is similar to the blood-tumor 
already described, but it contains, instead of blood, a serous fluid, 



380 DEFORMITIES OF THE AURICLE. 

which is sometimes of a syrupy consistence and appearance. It arises 
suddenly from an unknown cause, without a previous injury or in- 
flammation. The treatment is the same as for hematoma, — incision, 
etc. 

Intertrigo. — An excoriated condition of the skin on the adjoin- 
ing surfaces of the auricle and mastoid process is of frequent occur- 
rence among children of the poor. It may he due to an impoverished 
condition of the blood, but is more likely to be caused by uncleanli- 
ness and the harmful habit of binding the ears down against the head 
by close-fitting caps. The skin denuded of its cuticle presents a red, 
raw, moist appearance, but it is smooth and without thickening, in 
this respect differing from eczema, which may be ingrafted upon it. 
The trouble is aggravated by the efforts of the child to relieve the 
intense itching by scratching. The treatment is similar to that for 
eczema, except that dry applications are indicated, as in the weeping 
form of eczema. Powders are preferable, and of these aristol is suffi- 
cient. The binding caps must be interdicted and the irritated sur- 
faces kept apart. 

Miscellaneous. — Herpes, pemphigus, and syphilis of the auricle 
are very infrequent lesions that differ in no way from the same affec- 
tions of other parts of the cutaneous system and require no different 
treatment. Not being diseases peculiar to the ear, their description 
will be omitted here. 

DEFORMITIES OF THE AURICLE. 

Arrested and excessive development of the auricle in relation to 
degeneration have been made the subject of extensive investigation 
by E. S. Talbot, of Chicago; Spitzka, and others; but the discussion 
of this phase of the subject lies beyond the province of this book. 
Talbot's illustrated article, from which Fig. 140 is taken, appeared 
in the Journal of the American Medical Association for January 11, 
1896. 

Auricular deformities may be divided for convenience into con- 
genital and acquired. Congenital deformities may be classified a; 
correctible and irremediable. Acquired deformities fall under two 
headings: those resulting from disease and those from injuries. 

Hypertrophied Auricle. — The most common defect is the large, 
flattened, wing-like ear that stands out conspicuously from the side oJ 
the head (Fig. 140). This ear-marls serves as a butt of jest for tin 
child's companions, and makes life a burden to the hearer. Its ex- 



DEFORMITIES OF THE AUEICLE. 



381 



aggerated prominence suggests its prototype among the lower animals, 
the mule-ear. The natural surface inequalities are diminished, the 
border of the helix is often thin and expanded, and the whole flaring 
pinna appears as if it had been subjected to constant pulling or 
pressure. 

While a large percentage of these cases are congenital, that bar- 
barous mode of petty punishment — pulling the ears — may account 
for a certain amount of this deformity. We have been led to this 
conclusion by information elicited in many instances. The pressure 
produced by the tight caps so much in vogue with some people may 
be a factor. 

The treatment is operative. The author has proceeded in two 
ways: by reducing the actual size of the auricle, and by effecting a 




Fig. 140. — Hypertrophied Auricle. 



corrective amount of adhesion between the auricle and the mastoid 
process. The first operation is done by removing an elliptical section 
of the cartilaginous framework and the corresponding integument 
on the posterior surface and bringing the edges of the wound together 
with sutures including the cartilage. The long diameter of the 
ellipse is, of course, vertical. The cartilage must be dissected out 
without penetrating the skin of the anterior surface. By making 
accurate measurements and marking the size and shape of the section 
to be removed, the result will be satisfactory. The auricle is then to 
be dressed with aristol, antiseptic gauze, and the net bandage. This 
bandage is made of white mosquito-netting, moistened through just 
before applying, and it dries in place somewhat like the plaster band- 
age. Union by first intention is had and the stitches are removed as 
soon as the adhesion is firm. This method is superior to the removal 



382 



SCROLL-EAR AXD ASSOCIATED DEFORMITIES. 



of the skin alone, in which case the resilience of the cartilage tends 
to tear ont the sutures or bulge forward the anterior surface unduly. 

The second method is easier to practice, and I have given it pref- 
erence for a number of years. The auricle is pressed against the side 
of the head in such a way as to give it in ever}- part a little less pro- 
jection than it ought to have. Now the line of junction is marked 
throughout its whole extent on both auricle and head. The section 
of skin included within these lines is dissected out in a thin layer so 
as to leave a denuded surface; the edges of the wound are approxi- 
mated and sutured with the stitches close together and penetrating 
the subcutaneous tissues. The dressing and subsequent treatment are 
the same as after the first operation. 

This corrects a most unsightly deformity and may result in a 
beneficial influence on the temper and happiness of the patient for 
the remainder of his life. So far as we have been able to learn, this 
method of operating had not been practiced previously to its intro- 
duction by the author. 

Scroll-ear and Associated Deformities. — There is a deformity of 
the auricle in which the border of the helix turns forward and down- 
ward in a scroll-like roll. In such cases as I have seen the auricle is 
diminutive in size and does not present favorable conditions for an 
operation. In certain instances this condition amounts almost to 
obliteration of the pinna, and the auditory canal is absent. To illus- 
trate, we will cite one of the cases reported by the writer to the Tenth 
International Medical Congress, held in Berlin : — 

A girl, 8 weeks old, was brought to my clinic October 10, 1885. 
There was a congenital deformity of one auricle and absence of the 
external auditory meatus of the same ear. The auricle was rudi- 
mentary and doubled forward upon itself. It appeared shrunken and 
pinched, and had a large, hard nodule and several indentations in that 
part of the helix that corresponds to the keystone of an arch. 

It is interesting to note, in this connection, that the mother at- 
tributed the deformity of the auricle to the fact that, about the fifth 
month of gestation, her elder child bit the mother's ear severely, at 
just that point that corresponds to the greatest auricular deformity 
in the baby. 

At the point where the canal ought to have been there was a 
depression or cul-de-sac that yielded to pressure, and imparted to the 
touch an impression as if there were an opening in the hone beneath. 

Four months later careful tests led us to believe that the child 



SCROLL-EAR AND ASSOCIATED DEFORMITIES. 383 

could hear with that ear. I operated to correct, as far as possible, 
the deformity of the auricle, and to ascertain if there were any bony 
meatus. On cutting down into the cul-de-sac where the canal should 
have been, we found nothing but a depression in the bone. No bony 
canal could be found, and it did not appear that further operative in- 
terference would be justifiable. However, a sufficient opening was 
maintained to give quite a respectable appearance of an external 
meatus. 

Virchow's Archives says: "Congenital anomalies of the external 
ear and its neighborhood are to be referred to early disturbances in 
the closure of the first branchial cleft, and are often associated with 
fistulas of the other branchial clefts, cleft palate, and other forms of 
arrest of development in the facial bones, — as, for instance, with uni- 
lateral atrophy of the face." 

Certain acquired deformities have already been noticed in con- 
nection with the diseases that produce them, — perichondritis, etc. 
Treatment can hardly avail to remedy them. Those resulting from 
injuries must be treated on general surgical principles, with care to 
prevent any closure of the auditory canal. The latter subject will 
be presented in the following chapter. 



CHAPTER XXXIII. 
DISEASES OF THE EXTERNAL AUDITORY CANAL. 

Inspissated and Impacted Cerumen. 

Impacted wax is a common condition that may give rise to 
serious results. It is really a symptom of disease, and often is provo- 
cative of other pathological manifestations. Recurring hyperemia or 
eczema of the external canal may excite the ceruminous glands to 
hypersecretion, and anomalies of the canal may prevent the natural 
process of elimination of the cerumen; so that for these two reasons 




Fig. 141. — Lever and Handle. 



it becomes dried and impacted. With the movements of the lower 
jaw, corresponding motion is imparted to the cartilaginous portion of 
the canal, which has the effect of working the accumulations of wax 
outward; but, when the mouth of the canal is very narrow and when 
exostosis or other mechanical obstructions occur, they prevent the out- 
ward movement of the secretion, and it stops up the canal effectually. 
Patients often contribute to this impacting process by their efforts to 
cleanse the canal with towels, etc., at the bath. The middle ear may 
not be involved in the diseased process, or both parts may participate 
in trophoneurotic changes due to central causes. There may be, 
moreover, a simple desquamative inflammation with an abundant ex- 
foliation of the epidermis. In these cases the ceruminous plugs con- 
sist of the fatty secretion, epithelial scales, hairs, etc., which are often 
horn-like in their hardness. 

Symptomatology. — The hearing may not be perceptibly dimin- 
ished, providing the remainder of the ear is in its integrity and the 
(384) 



INSPISSATED AND IMPACTED CERUMEN. 385 

plug does not completely fill the lumen of the canal; but sudden im- 
pairment of hearing and a stuffy sensation in the ear, with confusion, 
may supervene directly after a bath or profuse perspiring, occasioned 
by absorption of moisture and swelling in the plug. On the other 
hand, there is a gradual diminution of the hearing-power going on, 
which is scarcely observed by the patient until his friends call atten- 
tion to it. Tinnitus aurium often occurs, and, with complete blocking 
of the canal, intense subjective noises; autophony, or a hollow sound 
of one's own voice; neuralgia of the ear or of the temporal and supra- 
orbital regions; numbness about the ear and side of the face, reflex 
cough of a spasmodic character, and mental dullness. Children are 
often chided for inattention or inaptitude when they are the unfor- 
tunate victims of such an ear disease. In the latter case both ears will 
probably be found to be affected. Impacted cerumen gives rise to 
even more serious symptoms, for the plug, which is, in effect, a 




Fig. 142. — Hard-rubber Syringe. 

foreign body, may work inward until it impinges upon the drumhead, 
causing perforation or intralabyrinthal pressure, vertigo, and epi- 
leptiform seizures. After a suppuration of the middle ear has- 
ceased we have found these large plugs blocking the exit for pus when 
a fresh cold has set up another suppurative inflammation. In such 
cases the pus may burrow inward and fill the mastoid cells, and even 
seek the cranial cavity before it can dislodge or penetrate these 
stone-like plugs. Their presence sometimes is sufficient to cause ab- 
sorption of the canal-walls and an immense increase in the size of the 
canal. After their removal the skin beneath is often inflamed and 
appears more like mucous membrane than healthy integument. 

Diagnosis. — The diagnosis is easily made on inspection of the 
canal, for the dark-brown or black mass is plainly visible, obstructing 
a view of the drumhead. 

Prognosis. — The prognosis depends upon the condition of the 
middle ear and labyrinth. If they are healthy the hearing will be 

25 



386 INSPISSATED AXD IMPACTED CERUMEN". 

restored and the subjective s} 7 mptoms removed upon the extraction of 
the cerumen. 

Treatment. — The treatment consists (1) in the complete removal 
of the plug and (2) in remedies addressed to any pathological condi- 
tion revealed by its extraction. If one is adept in the manipulation 
of ear instruments he can dextrously pull out the plug with the lever 
(Fig. 141) found among the middle-ear instruments (Fig. 181). It 
should be passed into the canal with the lever horizontal, next the roof, 
and carried far enough so that when the lever is turned downward it 
will imbed itself in the cerumen. The latter may be so hard that quite 
a considerable pressure must be exerted to penetrate it, or it may be 
so soft that only a part, instead of the whole plug, will glide out with 
the lever when traction is exerted. Care should be taken not to tDuch 
the drumhead or produce any abrasion of the canal-wall with the 




Fig. 143. — Alpha Syringe. 

lever. Those who are not practiced in ear-work had far better use 
the syringe. The continuous-flow rubber syringe with hand-bulb to 
regulate the pressure is the best. The glass syringes usually sold un- 
der the name of ear-syringes are of no account whatever for this pur- 
pose. The hard-rubber piston syringe (Fig. 142) is made for the ear 
with a flange to prevent its being introduced too far, but patients are 
likely to insert the nozzle so far that the flange stops up the canal 
opening, thus forcing the plug farther inward, or, when the plug is 
out, exerting undue pressure on the drum-membrane or even ruptur- 
ing it, The Davidson alpha or omega syringe (Fig. 143) has proved 
even more effective than the I'ountain-irrigator. The stream should 
be thrown so as to enter any space that may he seen between the 
canal-wall and the cerumen, rather than against the centre of the 
plug. As milch force should he employed as the patient can hear with 
comfort, and without producing dizziness. The water must he as 



DIFFUSE INFLAMMATION OF THE EXTERNAL MEATUS. 387 

warm as can' be easily borne, and a quart or more may.be necessary 
at a sitting. The emulsifying and disintegration of the ceruminous 
mass can be much facilitated by preceding the use of the syringe with 
an instillation of hydrogen dioxide or a -i-per-cent. solution of bicar- 
bonate of sodium in glycerin and water, equal parts. The ear should 
be filled with this fluid warmed, several times during the day, allow- 
ing it to remain a quarter of an hour; then the mass breaks up readily 
and washes out with the injections. The canal should afterward be 
dried, smeared with warm vaselin, and protected for a few days with 
clean cotton. Any dermatitis should be treated according to the prin- 
ciples laid down under the following heading. 

Diffuse Inflammation of the External Meatus. 

Diffuse inflammation may be acute or chronic in character and 
may include the whole extent of the canal, although it is usually con- 
fined either to the osseous or to the cartilaginous portion. In my 
experience it more often has affected only that part of the meatus 
that adjoins the drum-membrane, and frequently it was limited to 
the superior half of the canal and invaded the membrana flaccida. 

Pathology. — If seen early the canal-wall presents a bright-red 
and smooth aspect. When the inflammation becomes intense and in- 
filtration of the integument causes it to swell, the lumen of the canal 
is so encroached upon as to make an examination of the drum-mem- 
brane difficult or impossible. The walls then lie in contact and even 
press upon each other; so that introduction of the smallest funnel 
is impracticable. When the membrana tympani is involved and can 
be seen, it may look red and swollen and the hammer-handle may be 
wholly invisible. A white coating of epidermis is frequently found 
hying loosely in the canal, and can be easily detached and removed 
in casts. In an advanced stage ulceration and granulations are found. 

Etiology. — The common habit of working at the ears with ear- 
spoons, hair-pins, common pins, matches, and other hard substances 
is a prolific cause of inflammation of the canal. Instilling oil that 
becomes rancid, foreign bodies, and vegetable parasites act as ex- 
citing causes. 

Symptomatology. — In the first stage, or hyperemia, there may 
be no pain or impairment of function, and the patient remains un- 
conscious of any unusual condition except for the itching. His at- 
tempts to relieve this only serve to increase the irritation, and, as the 



388 FURUNCULOSIS. 

disease progresses, pain of a severe character is developed. The move- 
ments of the jaw and pressure about the ear aggravate the pain. 
With the occurrence of profuse transudation the hearing is dulled, 
and tinnitus and even vertigo may ensue. The more copious the 
exudation, the greater the stenosis and impairment of hearing. In 
very old cases the canal is found full of an offensive, thick, and greasy 
secretion. 

Diagnosis. — The diagnosis is not easy to make when the stenosis 
is great. It may be impossible to differentiate between an affection 
of the canal alone and one affecting both the canal and middle ear. 
A microscopical examination of the exfoliated epidermis for micro- 
cocci and vegetable fungi may clear up the diagnosis. 

Prognosis. — This depends upon the extent of the inflammatory 
process. It may invade the tympanic cavity and produce suppuration. 
It may extend to the bony walls and even to the mastoid cells and 
cranial cavity, but such results are rare. The lumen of the meatus 
may be permanently contracted or obstructed by adhesive processes. 
But the usual course under proper treatment is favorable. 

Treatment. — If the inflammation is very active and painful and 
the stenosis complete, an icebag (Fig. 194) should be applied. Ab- 
straction of blood by leeches may give relief, two being applied in 
front of the tragus. If the canal is sufficiently open to permit of 
washing it out, a 3-per-cent. hot solution of carbolic acid should be 
used until the canal is thoroughly cleansed. Then it should be dried 
with cotton without friction, and covered with a coating of aristol 
by means of a small powder-blower (Fig. 144). If this does not stop 
the secretion in a few days, nosophen or the fine boric powder should 
be substituted. 

Furunculosis. 

Synonyms. — Furuncle; boil; follicular or circumscribed inflam- 
mation of the external meatus. 

Pathology. — Furuncles are generally limited to the cartilaginous 
portion, and most frequently to the posterior or anterior wall of the 
auditory canal. Although they may be secondary to a middle-ear 
inflammation, they are frequently idiopathic in character. Furuncles 
appear singly, in groups, or in successive crops, and probably are due 
to the staphylococcus pyogenes aureus and albus entering the hair- 
follicle or sebaceous gland, or to some trophic change in the nervous 
supply of the meatus. 



FURUNCULOSIS. 



389 



Etiology. — r- Any irritation of the canal predisposes to furuncle; 
foreign bodies, irritating instillations, ear-spoons, matches, discharges 
from the tympanic cavity, too frequent syringing, and vegetable para- 
sites. The same may be said of a general impairment of health, dia- 
betes, anaemia, and dyspepsia. 

Symptomatology, — The onset of the attack is attended with a 
sense of fullness or itching, followed by tenderness on touch, pains of 
a throbbing character, and, as the swelling increases, impaired hear- 
ing and subjective noises. The pain becomes intense for a day or two 
and subsides on the rupturing of the boil. Movements of the jaw 
increase the pain to such an extent that mastication is out of the 
question. When the furuncle is located on the anterior wall, the 
tragus may become red, swollen, prominent, and sensitive; when it 




Fig. 144. — The Author's Small Powder- blowe'r for the Ear. 
operated by a small rubber bulb. 



It can also be 



is on the back wall, the swelling may be sufficient to protrude the 
auricle and simulate the appearance of mastoid periostitis. Occasion- 
ally the cervical glands, and the lymphatic glands over the mastoid 
process, when they are present, become infiltrated. For the first two 
or three days the fever, headache, and furred tongue denote a gen- 
eral systemic disturbance. 

Diagnosis. — This is not difficult on careful inspection with bril- 
liant illumination. This disease is not likely to be confounded with 
any other, when we consider the prominent symptoms. The boils 
are easily detected with the probe. 

Prognosis. — The disease usually runs its course in about a week, 
and unless successive crops occur, or unless the general health is im- 
paired, the trouble is over. But it should not be forgotten that in 



390 PAKASITIC INFLAMMATION OF THE EXTERNAL MEATUS. 

certain instances the inflammation has invaded the .tympanum, the 
mastoid, and even the cranial cavity. 

Treatment. — The first indication is to allay pain, if there be any, 
for which bromidia internally and cocaine locally are effective, the 
former in teaspoonfnl doses in water every half-hour or hour for an 
adult until pain ceases, and the latter in a very warm, 10-per-cent. 
solution. As soon as the pain is relieved we should cleanse the meatus 
with hydrozone (dioxide of hydrogen, or peroxide) comfortably warm. 
It can be warmed to a little above blood-heat (105° F.) without im- 
pairing its effectiveness. Its effervescent action washes out the canal, 
and its bactericidal property strikes at the root of the trouble. After 
cleansing, a 20-per-cent. solution of camphor-menthol on cotton ex- 
erts a comforting and curative influence. It is to some degree a local 
anaesthetic, antiseptic, and a constrictor of the capillary blood-vessels. 
A 12-per-cent. solution of carbolic acid in glycerin' acts similarly. 
They are applied, like the cocaine, on a cotton tampon. As soon as 
a point of distinct fluctuation can be made out, it should be incised 
deeply through the centre, under cocaine, and pressure exerted about 
the base to express all pus or necrotic tissue. After once thoroughly 
cleansing the canal, it is important to keep the skin as dry as pos- 
sible in and around the meatus, on the same principle that guides 
us in the treatment of suppuration of the middle ear. Thomas Barr 
has obtained marked benefit from the ointment containing 4 grains 
of iodoform or boric acid, and 2 grains of menthol in a drachm of 
vaselin. This is smeared on cotton pledgets and placed so as to pro- 
duce a little pressure on the boil, but the plugs should be changed 
as often as an accumulation of the discharge requires. 

Subsequent treatment consists in the application of a small 
amount of yellow-oxide-of-mercury ointment, 5 grains to the ounce; 
salicylic-acid ointment, 3 per cent.; or carbolic-acid ointment. Proper 
treatment is addressed to the general health. Sulphide of calcium is 
credited with the power of aborting or modifying the disease. 

Parasitic Inflammation of the External Meatus. 

Synonyms. — Mycosis; otomycosis; mycomyringitis; aspergillus; 
myringitis parasitica; car-mold; aural fungi. 

Pathology. — Vegetable parasites in large variety are found in 
the auditory canal, but ii is beyond the scope of this work to give a 
detailed description of the microscopical appearances of these fungi. 



PARASITIC INFLAMMATION OF THE EXTERNAL MEATUS. 391 

For an extended study of this subject the reader is referred to 
Burnett's exhaustive work. The most frequent varieties are the 
dark-brown aspergillus, or nigricans ; the yellow, or flavescens ; the 
green, or glaucus; and the grayish black, or fumigatis. When these 
parasites once find lodgment in the ear they multiply rapidly. This 
usually begins upon the drumhead, and the growth and the resulting 
inflammation extend outward until the whole meatus may be involved: 
These cases are not often seen until they are so far advanced that the 
condition is generally one of complete covering of the drum-mem- 
brane and meatus with the mold. On removing the growth, which I 
have peeled out in a complete cast of the canal, the skin is red and 
raw in appearance, as though robbed of its epidermis. 

Etiology. — A damp atmosphere favors the growth of these para- 
sites. The middle-aged and poor are the most frequently attacked. 
The common use of oils by the laity predisposes to this disease, as 
does any decomposing secretion or substance in the ear. 

Symptomatology. — Ear-mold may exist for a long time without 
the patient becoming aware of its presence, but when an active in- 
flammation supervenes decisive symptoms develop. At first there is 
only an itching or irritation or feeling of fullness, followed by pain, 
subjective noises, and diminished hearing. In my experience there 
is rarely a discharge except when the disease is secondary to a suppu- 
ration of the tympanic cavity; but if the inflammatory action is severe 
a serous exudation occurs. Inspection shows in the black variety 
what is easily mistaken for a long-standing plug of inspissated ceru- 
men were it not that the surface of the obstruction has a velvety or 
coal-dust appearance. In case of the yellow aspergillus, the parts look 
as though they had been sprinkled with finely powdered mustard or 
yellow pollen. On removing the false membrane formed by the mold, 
its surface next to the skin is of a dirty, grayish-white color. I have 
found this growth ingrafted on ceruminous plugs which required con- 
siderable time and care in removing. After their removal there was 
revealed not only the characteristic inflammatory condition, but an 
enormous distension of the meatus, due to pressure and the absorption 
of the canal-walls. 

Diagnosis. — Having in mind the appearances described, the diag- 
nosis is not difficult under good illumination, but a microscopical 
examination will set all doubts at rest. 

Prognosis. — This disease is rapidly amenable to the following 
method of treatment, a few days or weeks, at most, effecting a cure. 



392 IMPERFORATE EXTERXAL MEATUS. 

Treatment. — The ear should be syringed with a quite warm solu- 
tion of bichloride of mercury in water, 1 to 5000. Enough should be 
used to dislodge and remove all cerumen, discharges, false membrane, 
and debris that the ear may contain. The class of people in whom 
the mold is found work or live in a dirty atmosphere, and the ears 
are a label of this fact. After absolute cleanliness has been effected, 
the meatus should be filled with warm hydrozone (dioxide of hydro- 
gen, peroxide, H 2 2 ). This is left as long as it effervesces, then re- 
moved, and the canal is gently dried with absorbent cotton. Now 
the meatus is filled with a 12-per-cent. solution of carbolic acid in 
glycerin for ten minutes; then this is removed and a saturated solu- 
tion of iodoform in alcohol is substituted. The carbolic acid does not 
corrode the tissues in this combination, but acts as an antiseptic, be- 
sides anaesthetizing the inflamed skin sufficiently to admit of the 
strong alcoholic solution being used without producing pain. The 
iodoform solution is left in the ear with the patient's head inclined 
to the opposite shoulder for ten minutes, when it is allowed to drain 
out slowly, leaving a covering of iodoform powder on the surface of 
the drumhead and walls of the meatus. This treatment destroys any 
remaining fungi. The canal is then dried and dusted with a coating 
of aristol, and stoppered with absorbent cotton until the next treat- 
ment on the following or second day. Should there be a considerable 
exudation of serum, boric-acid powder may take the place of aristol 
or may be added to it. If the drumhead has been perforated or if 
the mastoid cells have been invaded, suitable treatment, such as will 
be detailed in the chapters on those subjects, must be adapted to such 
complications. 

Exostoses or bony growths irom the osseous section of the ex- 
ternal meatus are so rare that we will not enter into their considera- 
tion here, except to remark that unless they occasion serious trouble 
they do not require attention; but if they become obstructive they 
must be removed. 

Imperforate External Meatus. 

At the Tenth International Medical Congress the author reported 
four cases of complete closure or absence of the auditory meatus. — • 
two traumatic and two congenital. In the two congenital cases no 
external canal could be demonstrated. One of the traumatic eases 
was produced by a railroad accident that amputated the auricle, which 



FOREIGN BODIES IN THE EXTERNAL MEATUS. 393 

was replaced and carelessly sewed over the canal to present a good 
appearance at the funeral; but the patient recovered. A few years 
afterward the author made a new canal, maintained its patency by 
means of a hard-rubber tube, and succeeded in restoring the useful- 
ness of the organ. The other traumatic case was a man 32 years of 
age. It was caused by a wagon-wheel severing the auricle from the 
head when the patient was 3 years old. The same error was com- 
mitted in stitching the auricle over the mouth of the canal. When 
the patient came for treatment there was a discharge of pus from a 
very minute fistula in the roof of what should have been the canal. 
I opened the canal, cauterized the cicatricial tissues, and maintained 
the opening by means of a vulcanite tube. In the two congenital 
cases I operated on one, a girl 6 months old, but found no osseous 
canal; in the other, an infant of 14 months, no operation was ad- 
vised. Adhesions causing closure of the canal are very rare. 

Some of our authorities speak of imperforate external auditory 
canals as though they were of frequent occurrence; but among my 
records, embracing more than 21,000 cases of diseases of the ear, we 
found but 1 case of closure from exostosis, 3 cases of congenital ab- 
sence of the meatus, and 3 of traumatic closure. There were numer- 
ous cases of narrowing, and various irregularities of the canal, from 
causes that are not uncommon. 



Foreign Bodies in the External Meatus. 

It is a common occurrence to find peas, beans, pebbles, and glass 
beads that children have introduced into their own or their com- 
panions 7 ears. We have found flies, bedbugs, live moth-millers, etc., 
but flies are oftener found in suppurating ears. It is not uncommon 
to find oats and other foreign bodies that have remained in the ears 
for years without provoking symptoms that made their presence 
known. Sir William Bartlett Dalby found a piece of slate-pencil 
that had been in the ear for 30 years, and a stone that had been 
there for over 50 years. Notwithstanding this, a foreign body is a 
menace to the integrity of the hearing organ so long as it remains in 
the canal. It may at any time set up an inflammation either by 
mechanical irritation, or, if it be an organic substance, by swelling 
and by decomposition. 

These bodies are easily seen if the forehead-mirror, bright light, 
and a funnel are employed. But the funnel must not be allowed to 



394 FOREIGX BODIES IX THE EXTERNAL AUDITORY CAXAL. 

crowd the body down farther into the canal. Insects, if alive, should 
either be immediately picked out with the delicate forceps (Fig. 145) 
or drowned by filling the ear at once with warm water. Beans, corn, 
peas, etc., absorb moisture and swell so as to completely fill the canal 
until their pressure becomes painful. They are easiest removed by 
passing the little sharp hook, contained in the author's middle-ear 
case, over the grain with the hook lying in a horizontal plane next to 
the canal-roof; or, if there is greater space at any other point, we 
should choose it and carry the hook well over the berry, then turn the 
point toward the centre of the berry and press it firmly so as to imbed 
it in its substance. Careful traction will then extract it. Hard, 
inorganic bodies are not so easily extracted. Syringing is safest, with 
the head inclined toward the basin so that gravity will aid in their 
expulsion. They may be wedged into the meatus so that the current 
of water cannot dislodge them. Then the little blunt lever, instead 




Fig. 145. — Ear-forceps. 

of the sharp hook, may be passed behind the body and drawn upon, 
care being had not to allow it to slip over or around the body, leaving 
the latter behind. When glass beads work into the middle ear, the 
operation for extraction is not so simple a matter. The author has 
the ornament of a "ruby" ring that could not be removed from the 
tympanic cavity until we had detached the auricle and chiseled away 
a section of the bony canal. The "ruby" is five-sixteenths of an inch 
(eight millimetres) in diameter and cut similarly to a diamond; so 
that instruments could gain no hold upon the facets. D. B. St. John 
Eoosa and Albert H. Buck report similar cases. Roosa removed a 
shot from the middle ear, and Buck extracted a hard locusl bean by 
means of the same operation. 

Extreme care should be exercised, in efforts to remove foreign 
bodies, not to injure either the canal or drumhead and ossicles. Wo 
have soni numerous instances in which unskillful practitioners had 



FOREIGN BODIES IN THE EXTERNAL AUDITORY CANAL. 395 

mutilated the canal-walls and drum-membranes, and even extracted 
the little bones before they discovered that there really had been no 
foreign body in the ear. Such practices are appalling. It is fre- 
quently necessary to assure anxious parents that they and their chil- 
dren are mistaken, when they bring their little ones to have foreign 
bodies extracted, for we often find that there is absolutely no evidence 
that an}' foreign body has been there. 



CHAPTER XXXIV. 
DISEASES OF THE MIDDLE EAR. 

Injuries to the Drumhead. 

The drumhead is occasionally ruptured by blows (Fig. 146), ex- 
plosions, concussions from firearms, the pushing of pencils or straws 
into the ear, or by pulling the ears of children. Gorham Bacon says 
that during the laying of the foundations of the Brooklyn bridge 
many of the men working in the caissons suffered from rupture of the 
drumhead; but A. H. Smith, the medical officer in charge of the 
men, believed that, in all those who suffered from an aural affection 




Fig. 146. — Rupture of the Anteroinferior Segment of the Drumhead 
caused by a Box on the Ear. (After Politzer.) 

after working in the caissons, there already existed some obstruction 
to the entrance of air through the Eustachian tubes. The mere rup- 
ture of the membrane is not usually of very serious import, for it will 
probably close in a few days without treatment; but concussions or 
wounds may penetrate sufficiently to affect seriously the middle or 
internal ear. If no inflammation follow such accidents, the perfora- 
tion itself requires no treatment further than to protect it from the 
air-currents by a light pledget of sterilized cotton. The consequent 
affections are treated in their proper classifications. 

Inflammation of the Drumhead. 

Synonym. — Myringitis. 

Pathology. — Myringitis is of frequent occurrence and generally 
begins with an injection of the malleal plexus of vessels. At first 
(396) 



PLATE VIII. 



PLATE VIII. 



Fig. 1.— Normal ruembrana tympani of the right side, showing the incudo-stapedial joint. 

Fig. 2.— Hypersemia of the right tympanic membrane. Slight injection of the vessels running along- 
side of the hammer. Injection of the radiating vessels of the posterior segment, in a case of otitis media 
acuta. Duration, 9 days ; female patient ; age, 37 years. 

Fig. 3.— Injection of the radiating blood-ves'sels of the left tympanic membrane in a state of retro- 
gression. A case of acute otitis media of 10 days' standing ; female patient ; age, 45. 

Fig. 4.— Myringitis bullosa, showing formation of a blister the size of a hemp-seed, situated behind 
the umbo ; second day of the disease ; male patient ; age, 19. 

Fig. 5. — Myringitis granulosa with extensive formation of sharply defined wart-like elevations or 
excrescences on the lower segment of the tympanic membrane. Numerous punctiform light-reflections 
appear on the granular surface. Duration, 6 months ; age, 25. Completely cured after several applications 
of liquor ferri sesquichlorati. 

Fig. 6.— Myringitis granulosa chronica, the granulations covering nearly the entire tympanic 
membrane. Duration, unknown ; female ; age, 26. 

Fig. 7. — Catarrh of the middle ear, with secretion of an intensely yellow color in the lower portion 
of the tympanum, and bulging of the lower segment of the drumhead* Duration, 2 weeks ; for 4 davs 
there had been a marked injection of the vessels surrounding the handle of the hammer and those supply- 
ing the upper segment of the membrane. Acoumeter heard only on contact ; conversational voice close to 
the ear. Age, 15. 

Fig. 8. — Secretive middle-ear catarrh, with great retraction of the tympanic membrane, which is of 
a yellowish-gray color. The posterior fold of the membrane is extremely prominent, and the lateral and 
middle folds of Shrapnell's membrane are well defined. Duration, 14 days ; age, 28. 

Fig. 9. — Chronic middle-ear catarrh. Eetraction of the tympanic membrane, the hammer being 
invisible owing to the great prominence of the posterior fold, which describes a curve extending from the 
short process above and in front and terminating below and posteriorly in the lower segment of the 
membrane. 

Fig. 10. — Chronic catarrh of the middle ear with cretaceous deposit in the drumhead, anterior to the 
hammer-handle. 

Fig. 11. — Two crescentic deposits of chalk embracing the handle of the malleus. Great impairment 
of hearing associated with continuous subjective noises in the ear. Duration more than 6 months ; female ; 
age, 18. 

Fig. 12. — Crescentic chalk deposit enveloping the umbo, or the deep concavity corresponding to the 
inferior extremity of the malleus. 

Fig. 13. — Acute suppurative inflammation of the middle ear. Tympanic membrane of a red color 
and covered with a thin layer of exudation. A round perforation in the lower segment. Otorrhcea is said 
to have developed one hour after the painful symptoms began. Duration, 14 days ; age, 39. 

Fig. 14 — Acute suppurative inflammation of the middle ear, tubercular. Anterior half of the 
drumhead is deeply injected, the posterior segment has a pale-gray color. Behind the malleus are two 
small tubercular excrescences, a capillary blood-vessel crossing them from above. Two minute punctiform 
perforations above the tubercles. Duration, 5 days ; age, 25. 

Fig. 15. — Acute suppurative inflammation of the middle ear. Drumhead is yellowish gray, the 
external layer of the membrane appearing quite loose. Processus brevis scarcely visible. Beneath the 
umbo is a minute perforation. Duration, 12 days ; age, 33. 

Fig. 16. — Chronic suppurative inflammation of the middle ear. Oval perforation in the anterior, 
inferior quadrant of the drumhead ; round perforation in Shrapnell's membrane. The external layer of 
the remaining portion of the membrane is quite loose and of a gray color. Duration of the discharge from 
the ear was 2 years ; age, 28. 

Fig. 17. — Chronic suppurative inflammation of the middle ear ; round perforation in the superior 
segment of the drumhead. The mucous membrane of the tympanic cavity is of a dark-red color, and the 
drumhead of a light-gray color. The short process is visible. Age, 11. 

Fig. 18. — Chronic suppurative inflammation of the middle ear. Large defect of the posterior half of 
the drumhead. The mucous membrane covering the promontory is dark red and shining ; the remaining 
portion of the membrane is grayish red. The handle of the hammer is hardly visible. In the upper portion 
of the perforation the round head of the stapes can be seen. Duration, 10 years ; age, 41. 

Fig. 19. — Chronic suppurative inflammation of the middle ear, with extensive destruction of the 
membrana tympani. Toward the periphery is the narrow, grayish-white remnant of the membrane, The 
mucous membrane of the inner wall of the tympanum is deeply red and swollen. The handle of the 
mallet occupies its normal position, hanging free in the perforation. Disease continued from childhood ; 
age, 22. 

Fig. 20. — Chronic suppurative inflammation of the middle ear ; very large perforation of the drum- 
head ; remaining portion grayish yellow and thickened; somewhat bulging on account of a dark-red 
polypoid growth in the region of the promontory. Short process is barely visible. Duration, 10 years ; 
female ; age, 29. 

Fig. 21. — Dry perforation below the umbo, the size of a pin-head : blood-vessels around the handle 
of the hammer are much injected The drumhead is grayish red. In front and behind the malleus are 
crescentic, serrated deposits of chalk. Duration, since childhood ; aee, 41. 

Fig. 22.— Cicatricial adhesion of the drumhead to the inner wall of the tympanum. The membrane 
is retracted behind the malleus and attached to the incudo-stapedial joint. The anterior portion of the 
drumhead, also, is retracted and attached to the inner wall of the middle ear. The unusually prominent 
handle of the mallet becomes less prominent as it extends downward toward the promontory, which is 
covered by scar-tissue. Duration, unknown ; age, 28. 

FIG. 23.— Defect of the drumhead, only a small portion remaining, which is connected with the 
retracted handle of the mnllet. The inner tympanic wall is of a grayish color. In front of the opening 
leading to the Eustachian tube a membranous septum is stretched, with a minute perforation. Duration, 
15 years ; female; age, 56. 

I'Ki. 24. — Destruction of Shrapnell's membrane ; large bony defect of the outer wall of the attic, 
through which the* disarticulated head of the hammer is visible. The InCUS Is missing. The tympanic 
membrane ifl opaque and marked by a sharp, white border toward the defect. Duration, 20 years; 
female ; age, 30. 

Reproduced, by permission, from the "Atlas der Belenohtnmtsbilder des Trommelfells in gesunden und in Kranken 
Zustandti." Fourteen (dates, 39u drawings, von 1'rof. A. Politzer. Wien bei Braumuller k Solm. 



PLRTE mil, 




INFLAMMATION" OF THE DKUMHEAD. 397 

they can be distinctly seen like minute red threads extending down- 
ward along the hammer-handle, but as the hypersemia increases they 
appear to coalesce until there is an even diffusion of redness envelop- 
ing the handle and overspreading the membrana Shrapnelli (Fig. 118) 
like an intense blush. This condition may co-exist with a dermatitis 
of the superior integumentary wall of the external meatus. In these 
cases one cannot discern any line of demarkation between the lining 
of the wall and the drum-membrane. I remember to have seen an 
abscess in the drumhead of a violinist, located in the region of Prussak's 
space (Fig. 147). The hook-knife (Fig. 181) was introduced from 




Fig. 147. — Section through the Tympanic Membrane, Malleus, and 
Upper and Outer Tympanic Wall of a Decalcified Preparation. (After 
Politzer.) Is, Ligament, mall. sup. le, Ligament, mall. ext. s, Mem- 
brana Shrapnelli. o, Prussak's space, r, System of cavities between the 
body of the malleus and incus and the external tympanic wall, t, Ten- 
don of the muse. tens. tymp. 

above and brought downward and outward, dividing the external wall, 
thus laying the little abscess-walls open to view. Occasionally hsemor- 
rhagic effusions are seen, but the blisters described by Politzer we 
have rarely observed. When the inflammation extends over the whole 
area of the membrane it assumes a cherry-red color, shining at first, 
swollen and dusky after serous infiltration takes place (Plate VIII). 

Etiology. — The cause usually lies in wind or cold water reaching 
the drumhead (swimming), instillations of irritating substances into 
the ear, fungi, or acute cold in the head. 

Symptomatology. — The hearing is not necessarily diminished for 
speech, but, on the other hand, there may be increased sensitiveness 



398 EUSTACHIAN TUBAL CATARRH. 

to noises. The pain is often severe and throbbing in character, ac- 
companied with a feeling of fullness and pressure and subjective 
noises. Pain may be referred to the side of the head and neck, as 
well as to the ear itself. 

Diagnosis. — In the early stage in the absence of pain this is not 
difficult, for the symptoms are not indicative of middle-ear inflam- 
mation except the appearance of the membrane. In mild cases the 
patient may not be aware of the presence of the trouble, although 
inspection reveals it, and the hearing is believed to be normal; but 
in acute middle-ear inflammation the Eustachian tube is usually in- 
volved, a rapid serous exudation takes place, and swelling of the mem- 
brane, with marked impairment of- hearing. All the symptoms are 
characteristic of a more profound disturbance. After the inflamma- 
tion extends from the drumhead to the middle ear the differential 
diagnosis is out of the question and immaterial. 

Prognosis. — This is favorable, the disease being generally limited 
to a few days or a week. 

Treatment. — If the pain is not severe the symptoms subside on 
warming pure vaselin and letting it run down upon the drum-mem- 
brane. Then the ear is closed with cotton to retain it for twenty- 
four hours. In severe pain an 8-per-cent. solution of cocaine or 
eucaine, quite warm, gives relief used in the same manner. Xo other 
treatment is necessary except for complications or after-effects of the 
disease. 



Eustachian Tubal Catarrh, or Salpixgitis. 

Pathology. — In Eustachian salpingitis the mucous membrane 
lining the tube may be simply hypersemic or highly inflamed. Since 
it is lined with a continuation of the same mucous lining as that of 
the naso-pharynx, on the one hand, and of the tympanic cavity, on 
the other (Fig. 148), any inflammatory action in one is likely to spread 
along the membrane to another part, just as an erysipelatous inflam- 
mation of the skin travels along the integument from one part of the 
body to another. In a transitory inflammation of the tube, mild in 
character, the mucous membrane alone may be affected, with only 
slight swelling and diminution of its calibre; but in a severer grade 
the submucous layer becomes involved, transudation of the fluid ele- 
ments of the blood takes place, and great swelling and stenosis or 
complete closure of the tube occur. As a result of the latter condi- 



EUSTACHIAN TUBAL CATAREH. 



399 



tion, new connective-tissue formation may make the narrowing or im- 
perviousness of the tube permanent. Both the inflammation and the 
constriction are principally confined to the cartilaginous part of the 
tube, and the connective-tissue strictures to the middle of this portion. 
Granulations sometimes result from the inflammation. 




Fig. 148. — Eustachian Tube and Tympanic Cavity. (After Politzer.) 
a, Membrana tympani. 1), Head of the malleus, c, Lower end of the 
handle of the malleus, d, Body of the incus, e, Short process of the 
incus, f, Tensor tympani. g, Orifice of the Eustachian tube, li, Isthmus 
of the tube, i, Tympanic mouth of the tube. 



Etiology. — Tubal catarrh is rarely an idiopathic disease, but re- 
sults either from an attack of acute coryza, or pharyngitis, or from a 
middle-ear catarrh. Cold winds blowing on the side of the neck, a 
blow, or irritating fluids in the naso-pharynx may act as causes. The 
presence of hypertrophied or inflamed oral tonsils, or of adenoid 
vegetations in the vault of- the pharynx, which are the seat of fre- 



400 EUSTACHIAN TUBAL CATARRH. 

quently recurring attacks of inflammation, predisposes to the disease. 
Moreover, they form a nidus for pathogenic bacteria. 

Symptomatology. — In light attacks there are only slight deafness 
and subjective noises, which increase with the severity of the inflam- 
mation. When the tube becomes greatly swollen there may be vertigo, 
and pain referred to the side of the neck, back of the ramus of the 
lower jaw. Pressure toward the course of the tube reveals tenderness. 
Auscultation gives a high-pitched, squeaking noise during politzeriza- 
tion, and, if mucus is present, a rale also in a swollen condition of 
the tube. These are not necessarily present in the constriction due 
to connective-tissue growth. In the latter the noise may be wanting. 
It is difficult or impossible to inflate the ear, or it will require high 
pressure to do so. The drumhead is sunken on account of the rapid 
absorption of air in the tympanic cavity and loss of the normal ven- 
tilation by the tube. The lower extremity of the mallet' may lie close 
to the inner wall of the cavity, giving the hammer-handle a fore- 
shortened appearance, and causing the short process to project out- 
ward prominently toward the examiner's eye. The membrane about 
the process looks stretched and drawn into folds. 

Diagnosis. — This is not difficult and the principal points have 
been indicated in what has already been said. With no middle-ear 
involvement, the most striking result is obtained from inflation. The 
hearing is immediately restored and the differential diagnosis is con- 
firmed. 

Prognosis. — The attack of acute catarrh of the tube is readily 
subdued, and proper treatment will soon restore the parts to a normal 
condition. 

Treatment. — This must be directed to the condition of the tube 
itself, to the causes that induce the attacks, and to the predisposing 
causes. The most immediate relief is afforded the patient if we can 
at once inflate the middle ear. This restores the normal hearing, re- 
lieves the tension of the drum-membrane, reduces the engorgement 
of the blood-vessels by relieving the partial vacuum; removes the 
cause of dizziness, the impaction of the stirrup: and lifts the patient 
out of his mental gloom, — a condition characteristic of this disease. 
The catheter should be avoided, since its introduction into the orifice 
of the inflamed tube serves only to increase the irritation. Politzeri- 
zation is, by far, preferable, at first with air alone, to gently and 
gradually fill the tympanic cavity and restore the drumhead to its 
normal position. Too sudden inflation in this state may cause distress. 



EUSTACHIAN TUBAL CATARRH. 401 

vertigo, and nausea by the disturbance of the intralabyrinthal fluid. 
The tube being opened, it is my practice to inject with the improved 
innator (Fig. 134) either pure lavolin — a purified non-irritating fluid 
vaselin — or a weak solution of camphor-menthol in lavolin, 3 per cent. 
The former is bland and emollient, as well as protective to the in- 
flamed membrane. The latter relieves the pain, constricts the capil- 
lary blood-vessels, reduces the swelling and stenosis, and acts as an 
antiseptic and protective. If the tube does not readily yield to the 
inflation, 6 or 10 drops of sulphuric ether may be placed on the 
sponges of the inflator, and, with sufficient pressure from the com- 
pressed-air reservoir and while the patient swallows, this will, in most 
cases, reach the middle ear. There is not sufficient ether to produce 
irritation, but it is so volatile that it will penetrate where air alone 
fails to go. 

My experience differs somewhat from that of other observers con- 
cerning tubal affections. We have rarely met cases of constriction 
that we were not able to overcome without the use of the bougie. 
This may be attributed, perhaps, to the greater air-pressure employed 
in my work. Moreover, it is rarely found necessary to introduce the 
catheter, — for the same reason, no doubt. Handbags are little used 
in my private practice or in my hospital and college clinics, but, in- 
stead, we make use of air in reservoirs compressed by hydraulic com- 
pound pumps, Westinghouse air-pumps, or some other device sup- 
plying at least three or four times the amount of force obtainable from 
the rubber airbags. But the amount of pressure is regulated by valves 
and airmeters so as to place it under the accurate control of the op- 
erator and render it safe. 

Bougies have their disadvantages. They may abrade or lacerate 
the membrane of the tube arid penetrate its weakened walls, or they 
may be carried onward into the tympanic cavity and dislocate the 
ossicles or perforate the membrana tympani. Air and emollient or 
stimulating medicaments are devoid of these dangers. Generally but 
a few treatments are required to open the tube and maintain its 
patency. I remember but two cases in which it required as long as 
three weeks of treatment without the bougie to effect this result. 
One was in a chronic catarrhal condition with connective-tissue stric- 
ture, but the result was satisfactory. The other required the bougie. 
A v B. Duel reports excellent results from electrolysis for stenosis {The 
Laryngoscope, February, 1898). The second indication for treatment 
is the reduction of the naso-pharyngeal or tympanic catarrh that may 

26 



402 ACUTE INFLAMMATION OF THE MIDDLE EAK. 

have given rise to the tubal trouble. But, since these conditions and 
the predisposing causes are treated of in their proper sections, we will 
not make mention of them here. 

Acute Inflammation of the Middle Ear. 

Synonyms. — Otitis media acuta; acute tympanitis. 

Pathology. — Otitis media acuta presents at first a glow of red- 
ness of the lining mucous membrane of the middle ear, due to the 
beginning hyperemia. This is perceptible through a translucent 
drumhead, and is followed rapidly by an effusion of serum and mucus 
into the tympanic cavity. These stages of inflammation follow each 
other in quick succession, and the disease itself is of short duration. 
The mucous membrane becomes tumefied and the epithelium becomes 
opaque and exfoliated. In a certain form of acute inflammation which 
is especially characteristic of the epidemic influenza, or, as it is gen- 
erally known, the grip, there is so sudden an exudation as to cause 
rupture of the blood-vessels, and within twelve or twenty-four hours 
of the onset there is a copious, bloody, serous effusion and rupture of 
the membrana tympani. I have observed an influx of this type of 
the disease within a few days of the breaking out of the epidemic in- 
fluenza in Chicago. 

Etiology. — This affection most often results from a cold in the 
head, and may be caused by an inflammation of any portion of the 
upper respiratory tract and by the eruptive fevers. Cold winds blow- 
ing in the ear, getting wet, bathing, influenza, cauterizing the nose 
and throat, pouring or sniffing cold fluids into the nose, and the en- 
trance of soap and water into the auditory meatus are prolific causes. 
It is more common to childhood than adult life. F. C. Hotz believes 
that malarial poison is sometimes a cause. 

Symptomatology. — Sensations of itching in the ear sometimes 
call the patient's attention to it before the actual pain begins, but 
the pains in other instances come on suddenly and without warning, 
and rapidly increase in intensity until they become unbearable. Espe- 
cially is this the case in children, who are thrown into a fever, de- 
lirium, and even convulsions, so exquisite is the suffering. The pain 
is increased by sneezing, swallowing, and coughing, and it may ra- 
diate to the side of the head and teeth, or there is a sensation of 
numbness in the corresponding side of the head. Autophony, or a 
hollow sound of the patient's voice as perceived by himself, add.- to his 






ACUTE INFLAMMATION OF THE MIDDLE EAR. 



403 



discomfort. If great pressure is exerted by an abundance of exudation, 
giddiness is experienced. Undoubtedly the lab} T rinth often partici- 
pates in the disturbance to the extent of becoming hypersemic, in 
which case subjective sounds become intense and even rhythmic, vary- 
ing synchronously with the heart's pulsations. It is not unusual to 
meet with a mild type of this disease in which all the symptoms are di- 
minished in intensity and some are absent. Before the exudation oc- 
curs the hearing may show no impairment, but afterward it decreases 
proportionately to the amount of tumefaction and secretion. Bone- 
conduction is normal. 

Inspection reveals, in the beginning of the attack, a drumhead 
presenting the appearance described under the caption of "Myringitis" 
(Fig. 149 and Plate VIII). The malleal plexus of vessels is injected 
with blood; their tracery along the upper region of the hammer- 




Fig. 149. — Eadiate Vascular Injection of the Drumhead. (After Politzer.) 



handle is distinctly made out ; a red areola shows about the processus 
brevis, and later a glow of redness covers the membrana flaccida. As 
the inflammation progresses the red appearance extends to every part 
of the membrane until it looks like a ripe cherry in the ear. Later, as 
the serous infiltration increases, the outlines of the handle become 
dimmed and disappear; the lustre of the membrane is lost, and in its 
place a dull, swollen surface presents. When the tympanic cavity be- 
comes filled with secretions, inequalities of the surface of the mem- 
brane are visible, and a bulging in some part may indicate the pres- 
sure of fluid from within. Indeed, the whole membrane may become 
bulged outward, and the radiate traceries of the injected vessels show 
like the spokes of a wheel (Fig. 150). 

As the inflammation subsides the redness of the drumhead fades 
away, the pain ceases, the hearing improves, the noises diminish, and 
a general sense of relief takes the place of a stormy experience. The 



404 



ACUTE INFLAMMATION" OF THE MIDDLE EAE. 



membrana tympani assumes a lustreless, ashy-gray color, and its 
opacity remains for a considerable time, and may become permanent. 

Diagnosis. — There is little likelihood of confounding this disease 
with any other save myringitis alone. The latter forms a factor in 
the present case and can, without much confusion, be separated from 
it. In the inflammation involving the whole of the cavity all the 
symptoms of inflammation of the drumhead alone are augmented, 
while others are ingrafted upon it. The great impairment of hear- 
ing after effusion, the general symptoms, and their duration are 
decisive. Children work at the affected ear, press it against warm 
objects, or incline the head to the diseased side. 

Prognosis. — The tendency is to resolution in healthy patients 
under favoring circumstances. In the opposite condition the tend- 
ency is either to suppuration and perforation of the drumhead or 
to a chronic dry catarrhal state. 




Fig. 150. — Radiate Vascular Appearance in Acute Inflammation of 
the Middle Ear. (After Politzer.) 



Treatment. — In the first stage, or before the serous effusion has 
taken place or the pain has become severe, gentle inflation and filling 
the ear-canal with warmed pure or carbolated vaselin will suffice to 
give relief. When the pain has become intense, inflation must be 
made under very low pressure, as the movements of the drumhead, 
like those of an inflamed joint, are exquisitely painful. The patient 
in this stage should be put to bed to keep the temperature equable, 
a warm 8-per-cent. solution of cocaine may be instilled into the ear, 
and, if deemed necessary, 1 / 8 grain of morphia can be given in combi- 
nation with V 400 grain of atropia for an adult. If for any reason the 
morphia and atropia should not be prescribed, bromidia may be sub- 
stituted in teaspoonful doses, in water, every* half-hour until relief 
is obtained. Then it must be discontinued. The bowels and general 
health should receive proper attention. We have often found that 



ACUTE INFLAMMATION OF THE MIDDLE EAK. 405 

leeches gave speedy relief. Two Spanish leeches may be applied in 
front of the tragus and two behind the auricle for adults. The ex- 
ternal canal is stoppered with cotton so that the leeches cannot enter 
it. The skin is pricked until a drop of blood appears ; then the leech 
in a two-drachm vial, with its mouth at the opening of the bottle, 
is placed so that its mouth covers the drop of blood. The vial is 
held in position until the leech takes secure hold. Then the bottle 
is removed and the leech allowed to fill and drop off. This man- 
ner of applying leeches is given because few seem to be conversant 
with the subject, and this method removes the common objection to 
handling such repulsive animals. Especial care should be exercised 
to abstract the blood in middle-ear inflammation as much as possible 
from the region of the tragus, on account of the intimate relation of 
the blood-vessels of this region and the anterior wall of the meatus 
with the vessels of the tympanic cavity. If enough blood has not 
been abstracted after the leeches fill and fall off, more can be drawn 
by applying napkins wrung out of warm water. If there should be 
any difficulty in stopping the bleeding of the leech-bites, pressure 
applied to them will succeed. The artificial leech is also an excellent 
device, but occasions more discomfort. 

The common practice indulged in by the laity of pouring oils, 
onion-juice, etc., into the ear is a vicious one, since these become 
rancid and irritating and predispose to a subsequent inflammation. 
Poultices are also mischievous and favor suppuration and perfora-. 
tion of the drum-membrane. The author has seen the following sim- 
ple device, always convenient, give grateful relief : A piece of clean 
cotton is placed lightly in the mouth of the canal. A pipe is partly 
filled with tobacco and lighted. Then a piece of thin cloth is placed 
over the mouth of the pipe-bowl and gently blown through, while 
the lip-piece of the pipe-stem rests against the cotton pledget. This 
filters the warm smoke through the cotton into the canal, and a grate- 
ful sedative effect is soon obtained. I do not remember /to have seen 
this remedy mentioned, but its efficacy in the absence of other reme- 
dies has been demonstrated. 

Fever calls for antipyrin or its equivalent in some febrifuge that 
is less of a cardiac depressant. Phenacetin and acetanilid act well. 
Quinine, the enemy of the ear, must not be used. It aggravates the 
existing hyperemia and conduces to permanent deafness. Alcoholic 
drinks and smoking are prohibited, and any inflammatory condition 
of the respiratory tract must be vigorously combated. 






406 ACUTE INFLAMMATION OF THE MIDDLE EAE. 

If the pain and bulging of the drumhead continue, notwith- 
standing all efforts to counteract the disease, and rupture of the mem- 
brane is threatened, it should be incised with the paracentesis-knife 
(Fig. 167, No. 2), in the postero-inferior quadrant, so as to afford the 
most perfect drainage. A warm, 8-per-cent. solution of cocaine 
should be left in the ear for twenty minutes before the paracentesis, 
and, if the pain does not soon cease after perforating, more cocaine 
should be instilled, as hot as can be comfortably borne, so as to 
percolate through the perforation and reach the mucous membrane 
within. This w T ill give relief. The incision should be a long one, 
cutting through the entire area of the postero-inferior quadrant ver- 
tically. The longer it is, the more it relieves the tension of the nerves 
of the membrane and the freer the drainage. The paracentesis-knife 
must be absolutely sharp and dipped in alcohol before using. The 
perforation generally heals in a few days if no pus has formed. If 
we find suppuration has taken place, then we have a condition which 
is considered in the following chapter. 

After the pain is relieved, which should be the object of our first 
efforts, the ear may be inflated with as low pressure as will accom- 
plish it. The air-pressure in the tympanic cavity promotes absorption 
of any fluid contents and will likely improve the hearing. This treat- 
ment is administered daily for a few days. As improvement pro- 
gresses the treatments can be given at greater intervals until the 
normal condition is established. 

Diet, exercise, and clothing should be regulated on general hy- 
gienic principles. 



CHAPTER XXXV. 
DISEASES OF THE MIDDLE EAR (Continued). 

Acute Suppukative Inflammation of the Middle Ear. 

Synonyms. — Otitis media acuta suppurativa; acute suppurative 
tympanitis. 

Pathology. — The tissue changes already set forth in the descrip- 
tion of acute inflammation of the middle ear take place in the affec- 
tion now under consideration previously to pus formation. In the 
suppurative form the inflammatory action is more intense; the tis- 




Fig. 151. — Convexity of the Drumhead Due to Pressure from 
Within. (After Politzer.) 

sues break down; the drumhead bulges with the pressure of the 
accumulated fluids (Fig. 151), becomes softened, and, yielding to the 
consequent pressure, ruptures. The whole tympanic cavity becomes 
involved, and the purulent discharge may find its way into the mas- 
toid antrum and cells. This disease is practically a sequel of the one 
described in the foregoing chapter. 

Etiology. — The causes of acute inflammation of the tympanum 
and those that give rise to suppuration are identical, and to avoid 
unnecessary repetition the reader is referred to the preceding chapter. 
But, in the case of suppuration, there is probably an invasion of the 
middle ear by micro-organisms through the Eustachian tube. Bezold 
found the diplococcus pneumonias in suppuration of the middle ear 
in pneumonia. Streptococci or pneumococci are usually found in 
acute suppuration, followed by the staphylococci pyogenes. 

(407) 



408 ACUTE SUPPURATIVE INFLAMMATION OF THE MIDDLE EAR. 

Symptomatology. — The symptoms here are a repetition of those 
already described in treating of acute inflammation np to the point 
of pns production, but in a certain proportion of cases the acute in- 
flammation runs its course without the train of distressing symptoms 
there described. It often happens, especially in children, that the 
first intimation the parents have of any ailment is the appearance 
of a discharge from the little .one's ear. On the other hand, some 
children are so violently affected as to suggest meningeal or brain 
complication. In diseases that simulate intracranial affections the 
physician should never fail to examine the ears. 

Diagnosis. — Before perforation takes place it may be impossible 
to differentiate between a simple acute inflammation with serous ex- 
udation into the tympanic cavity and a suppurative inflammation. 
As soon as rupture of the membrane occurs and the muco-purulent 
fluid is discharged into the meatus the diagnosis is cleared up. The 
appearance of the perforation (Plate VIII), which can generally be 
seen after removing the discharge, and the presence of the latter not 
being due to an inflammation of the meatus, together with the whis- 
tling sound resulting from forcing the air through the perforation 
during politzerization, present the factors of a positive diagnosis. 

Prognosis. — If the habits of body are bad, — tubercular, syphi- 
litic, etc., — or if the suppuration result from diphtheria or scarlet 
fever, the prognosis is unfavorable; otherwise, when all the symp- 
toms are ameliorated soon after the discharge appears, the outlook is 
favorable. There is reason for apprehension if the severity of the 
symptoms continue unabated after a free exit for the secretions has 
been provided for, either by nature or the surgeon. The author has 
often observed that, when the inflamed parts showed pulsation and 
were very sensitive to the gentlest touch of the cotton-fluff, the sup- 
puration was difficult to cure. The pulsation, which is synchronous 
with the heart-beats, can be seen distinctly if bright light is caused 
to be reflected from a moist spot on the drumhead. The pulse can 
easily be counted in this manner. Bulging of either the posterior 
or superior wall of the meatus, or symptoms referable to the mastoid 
process, burrowing of pus, periostitis, or osteitis are indicative of 
serious complications. 

Treatment. — In the preceding chapter, in treating of acute in- 
flammation of the middle ear. arc given in detail the methods that 
should be adopted in acute inflammation up to the lime of suppura- 
tion and rupture or paracentesis of the membrana tympani, to which 



ACUTE SUPPURATIVE INFLAMMATION OF THE MIDDLE EAE. 409 

the reader is referred. Taking up the subject then, at the point where 
rupture has occurred by the efforts of nature to cast off noxious ma- 
terial and relieve pressure, the first observation to be made is relative 
to the capacity of the perforation to meet the necessity for free drain- 
age. If the fluids are copious and the opening is too minute to admit 
of sufficient freedom of exit to the discharge, especially if the pain 
be continuous, the perforation should be enlarged vertically, as has 
already been described in the treatment of otitis media acuta. The 
tympanum must also be rendered freely accessible to the surgeon for 
the purposes of cleansing, disinfecting, and medicating the inflamed 
membrane within. 

"J. H. Coulter favors a free incision of the membrane, with the 
incision carried along the superior wall of the canal." ("Year-book 
of the Nose, Throat, and Ear/' 1901.) 

Assuming now a free perforation, the external canal is dried out 
very gently with a fluffy cotton-twist projecting a quarter of an inch 
beyond the end of a small soft-silver cotton-carrier (Fig. 115). The 
cotton is rolled over the point of the carrier firmly enough to prevent 
it from penetrating the cotton and wounding the tissues, but beyond 
the twisted portion the cotton should be left in a downy tuft to absorb 
rapidly the fluids and to avoid any abrasion of the membrane. The 
cotton can be carried down into the fundus of the canal and brought 
in contact with the drumhead repeatedly until all the secretions are 
absorbed and extracted. As the last of these are dried up, the fluid 
from within the cavity may be seen oozing out, a drop at a time, or 
rolling down from a nipple-like perforation (Fig. 152). If one is not 
expert in the manipulation of these instruments, it is better to cleanse 
the canal by syringing it with a quart of water as warm as can be 
comfortabry borne, the water having been sterilized by boiling for ten 
minutes. 

After freeing the meatus of all discharges the ear is carefully 
inflated with as low pressure as will propel a column of air outward 
through the perforation. The discharges are by this means projected 
through the perforation into the canal with a whistling or bubbling 
sound. If too great force is exerted, unnecessary pain is caused. Any 
fluids ejected into the meatus are then removed; the canal is dried, 
and insufflated with aristol from the small powder-blower (Fig. 144). 
This remedy is preferable to boric acid in that it possesses a feeble 
ansesthetic property. It is an excellent cicatrizant, and, being an 
impalpable powder, it can be dusted through a narrow perforation. 



410 ACUTE SUPPURATIVE INFLAMMATION OF THE MIDDLE EAR. 

Or we may employ nosophen, which, having no odor or irritating qual- 
ities, with decided antiseptic and healing properties, possesses un- 
doubted merits. It is a very light, impalpable powder, that is easily 
thrown in the form of a dust over the surface treated, and it contains 
nearly 62 per cent, of iodine in combination. 

It is the practice of some aurists to instill alcohol into the ear 
during an acute suppurative inflammation, but there is danger of not 
only causing increased suffering, but of aggravating the inflammatory 
action. Moreover, the dry method of treatment is preferable, and 
had best be employed first. Great care should be exercised to prevent 
any infection of the ear by means of the cotton, the surgeon's fingers, 
or the powders used, and patients must be cautioned against placing 
impure cotton in their ears. 

A small pledget of absorbent cotton is introduced lightly into 




Fig. 152. — Nipple-shaped Bulging of the Posterior Portion of the Drumhead, 
on the Summit of which is the Perforation. (After Politzer.) 

the mouth of the meatus and allowed to remain until a further dis- 
charge appears. Patients are instructed to let their ears entirely 
alone in case they remain dry after treatment, but if the cotton be- 
comes moist with the discharge they may syringe the ear (Fig. 143), 
as previously described, and instill a warm, saturated solution of boric 
acid in water or rose-water, allow it to remain ten minutes, then let 
it escape, and close the ear lightly again with clean cotton. 

The cotton stopper protects the sensitive drum from cold winds 
or draughts and absorbs moisture. This constitutes an ideal dressing, 
and in suppuration of the ear, as of other organs, the drier the treat- 
ment, the better the results. The ear already presents the most 
favorable condition for the development and propagation of bacte- 
ria — warmth and moisture. This condition we must combat ; so that, 
whatever our treatment may consist in, the aim should be to leave 
the parts as dry as possible. For this reason boric acid is an excellent 



ACUTE SUPPURATIVE INFLAMMATION OF THE MIDDLE EAR. 411 

dressing, especially when all acute symptoms have subsided. How- 
ever, during the acute stage boric acid may cause pain for several 
hours after its application. TVe have met with quite a number of 
such instances in which it became necessary to discontinue the use 
of this powder. We have suspected that certain individuals possess 
an idiosyncrasy against it, but, if it produce no discomfort, excellent 
results may be expected. It absorbs moisture and dries the tissues. 
If fluids come in contact with it a saturated solution of boric acid is 
formed, which may percolate through the perforation into the middle 
ear and there exercise its feebly germicidal power. ~No powder, how- 
ever, should be firmly packed into the ear, for it would prevent the 
escape of discharges and cause them to seek an outlet elsewhere: 
through the Eustachian tube if it were fortunately pervious, or 
through the mastoid antrum and cells, or even by way of the internal 




Tig. 153. — Fluid Effusion in the Tympanic Cavity, Marked by a 
Bright Line. (After Politzer.) 

meatus or the tympanic roof to the cranial cavity. Moreover, it 
should never be forgotten how intimately the middle ear and mastoid 
spaces are related to the contents of the cranial cavity by the con- 
necting blood-vessels, lymphatics, and by occasional defects in the 
superior surface of the temporal bone. These conditions emphasize 
the necessity of always keeping the passageway for the flow outward 
unobstructed. 

In case the drum-membrane and the canal remain very sensitive 
and pain continues unabated in the ear, a 12-per-cent. solution of 
carbolic acid in glycerin generally gives relief. The acid anaesthetizes 
and disinfects without corroding the tissues when combined in this 
proportion with glycerin, and the latter unloads the blood-vessels of 
their superabundant serum. The turgescence of the vessels is dimin- 
ished and the pain relieved. General treatment is to be resorted to 
when the conditions demand it. The body should be protected from 



412 



CHRONIC CATARRH OF THE MIDDLE EAR. 



sudden atmospheric changes by wearing wool next to the skin. Fur- 
ther elucidation of this subject will be found under the heading of 
"Treatment" of coryza. 

Since the disease under consideration is largely the result of 
acute catarrh of the nose and throat, coincident treatment should 
always be addressed to the naso-pharyngeal affection, and our efforts 
must be directed toward removing any permanent causes of recurring 
attacks, such as hypertrophies in the nasal chambers, adenoid growths 
in the pharynx, and enlarged tonsils. (See chapters on these sub- 
jects.) 

Chronic Non-suppurative Inflammation of the Middle Ear. 

Under this name are classed hypertrophic middle-ear catarrh 
and adhesive middle-ear catarrh, commonly called sclerosis (see Chap- 
ter XXXYI). 




Fig. 154. — Circumscribed Bulging of the Drumhead. Due to Pressure 
of Fluid in the Middle Ear. (After Politzer.) 



HYPERTROPHIC, OR SECRETIVE, CATARRH OF THE MIDDLE EAR. 

Synonym. — Hypertrophic tympanitis. 

Pathology. — Hypertrophic, or secretive, catarrh of the middle 
ear generally occurs in association with a similar condition of the nose 
and naso-pharynx. There is an hypera?mic condition of the mucous 
membrane lining the tympanic cavity, with hypersecretion of a serou- 
or mucous character. The exudation may be visible (Figs. 153 and 
154 and Plate VIII) if the drumhead lias not lost its translucency, 
more especially when air has been forced through the Eustachian tube 
into the fluid, thereby causing bubbles or a frothy appearance. In this 
disease the tube generally participates to the extent of losing it- 
patency; so that the normal supply of air in the tympanic cavity is 
cut off. The result is that the air in the middle car is absorbed: 



HYPERTROPHIC CATARRH OF THE MIDDLE EAR. 



413 



that the resistance of the drumhead to the outer atmospheric pres- 
sure of nearly fifteen pounds to the square inch is lost, and the mem- 
brane is forced inward toward the inner tympanic wall. The effect of 
this encroachment upon the tympanic space is easily visible in the 
increased concavity of the membrane, the foreshortening of the ham- 
mer-handle, the emphasizing of the posterior fold, and the changed 
location of the reflection of light. 

The drumhead yields to the atmospheric pressure from without 
when the counteracting air-pressure from within is lost, and lies, pos- 
sibly, in contact with the inner wall, especially the posterior half. In 
this case it may so embrace the long process of the anvil and the poste- 
rior crus of the stirrup as to show their projecting outlines and those 
of the promontory and round window. The mallet-handle may at 
first seem to be invisible until one looks from below upward as much as 
possible, when it is seen occupying an almost horizontal position (Fig. 




Fig. 155. — Great Concavity of the Drumhead and Foreshortening of 
the Hammer-handle. (After Politzer.) 



155 and'Plate VIII), running directly inward until its lower extremity 
lies in contact with the inner wall of the cavity (Fig. 158). The short 
process is thrown outward by this position toward the examiner's eye 
like a little yellow knuckle covered with membrane that is stretched 
into tense folds above. If the drumhead is still lustrous the triangle 
of light has been moved from its normal position, or there is a cir- 
cular reflection of light from the most depressed section, or there may 
be several dots of light, owing to the irregular surface produced by 
the varying degrees of depression in different parts of the membrane. 
In an advanced stage these irregularities of retraction are due to an 
atrophied condition of one or more parts of the membrane, and, un- 
less a careful inspection is made, these atrophies may be easily mis- 
taken for cicatrices. The latter, however, are more clearly defined 
by the distinct line forming a border to a previous perforation and 



414 HYPERTROPHIC CATARRH OF THE MIDDLE EAR. 

now separating the cicatricial tissue from the opaque, thickened sur- 
rounding membrane. The atrophic area blends gradually in more 
indefinite outlines with the adjoining hypertrophic tissue. 

The manipulation of the massage otoscope (Fig. 114) shows these 
atrophic and cicatricial sections with unmistakable clearness. "When 
the air is rarefied in the canal, these spots bulge outward like balloons, 
as if they might burst. Indeed, they probably could be easily ruptured 
if much force were exerted. They show exaggerated movements when 
the remainder of the membrane and the mallet are completely quies- 
cent. But, when the drumhead is depressed against the inner tym- 
panic wall and has become adherent to it by organic adhesions, these 
adhesions prevent the depressed area from responding to the pneu- 
matic otoscope. 

In the advanced stage of this disease the drumhead may become 
very greatly thickened and of a milky opacity, and hypersecretion and 
impaction of cerumen are frequently found. 

Etiology. — Acute colds in the head, influenza, the eruptive fevers, 
chronic naso-pharyngeal catarrh, and syphilis act as the exciting 
causes of this affection. Impermeability of the Eustachian tube, with 
consequent rarefaction of the air in the middle ear, causes an exuda- 
tion of serous fluid, retraction of the drumhead, etc., which may only 
prove to be transitory if the cause of the tubal stenosis is speedily 
removed, or, if it is not, permanent tissue changes may occur, result- 
ing in the more serious conditions described. George A. Leland makes 
the point that ear disease results from frequent and forceful efforts 
to clear the nose. The air is blown into the middle ears with suffi- 
cient pressure to stretch the drumheads and cause ultimate relaxa- 
tion. 

Symptomatology. — This is not a painful affection, although in 
the early stages slight twinges or darting and shooting transitory pains 
may occur. Sensations of fullness in the ear, pressure, and as if some- 
thing were moving in the ear are complained of. The last symptom 
is produced by movements of the fluid contents of the tympanic cav- 
ity, owing to the varying positions of the head, ami to the entrance 
of air into the fluid through the tube. The last cause also gives rise 
to bubbling, snapping, and crackling sounds. These rales result from 
the separating of the walls of the Eustachian tube also, when it is 
involved, as air passes through. The viscous mucous secretion ag- 
glutinates the walls together, and as they separate the clinging 
mucus first sticks, then stretches into filaments; and finally the break- 



HYPERTROPHIC CATARRH OF THE MIDDLE EAR. 415 

ing of these occasions the crackling noises. The movements of the 
jaw aggravate these symptoms. Sensations of numbness in the corre- 
sponding side of the head, confusion of ideas and speech, irritability 
of temper, and autophony — or a disagreeable hollow sound of one's 
own voice, as if talking into an empty barrel — are characteristic of 
this disease. 

The swelling of the tissues and increased tension of the drum- 
head and ossicles may produce labyrinthal pressure with a sense of 
light-headedness, giddiness, and subjective noises, although the latter 
constitute one of the principal symptoms of sclerosis. The hearing 
varies greatly with the weather conditions. Low barometer and ther- 
mometer, with great humidity of the atmosphere, increase the im- 
pairment of hearing, the sensations of stuffiness and fullness, and tin- 
nitus aurium. Sudden changes to these atmospheric conditions from 
a warm, dry air are certain to aggravate the aural symptoms. Patients 
can predict approaching weather changes by the phenomena men- 
tioned. Alcoholic stimulants and colds in the head also increase 
these distressing symptoms. 

Diagnosis. — It is not difficult to determine the presence of the 
secretive form of catarrh. If the drumhead is yet translucent the 
line in the membrane indicating the surface of the liquid (Fig. 153) 
can be made out unless it extends above into the attic, or the pro- 
pelling of air into it can be heard to produce bubbling sounds, and 
in the early stages the hearing ma}^ not be greatly impaired or it is 
much improved by politzerization. The patient is generally young, 
bone-conduction for the watch and tuning-fork is good, and the dis- 
ease is far more amenable to treatment than sclerosis. 

Prognosis. — This is favorable if we can exclude heredit}^ bad 
sanitary influences, and general ill health, and if the attack is not of 
long duration. Especially is this so if inflation of the ear and removal 
of any contained fluid result in decided improvement in the symptoms 
and if the bone-conduction is good. But examination of the nose and 
throat will throw important light on this subject. If there are no 
hypertrophies and exostoses, but a simple catarrh of recent origin, a 
cure is rapidly effected. 

Treatment. — Attention must first be directed to the passages that 
lead to the middle ear. If there is a catarrhal condition of the nose 
and throat that may have given rise to the middle-ear disease, it 
should receive proper treatment at the same time with the Eustachian 
tube and tympanum. Permanent cure of the ear affection cannot be 



416 HYPEETEOPHIC CATAEBH OF THE MIDDLE EAE. 

effected so long as the exciting cause of snch attacks remains in the 
naso-pharyngeal tract. The Eustachian tube, if diseased, should be 
the subject of proper measures to render it permanently patulous and 
healthy. The air-douche by the Politzer airbag or the compressed- 
air apparatus is sufficient in many recent cases to cause absorption of 
secretions in the middle ear and the reduction of hyperemia and swell- 
ing of the mucous membrane. By this means the natural ventilation 
of the tube and tympanic cavity is effected and the drumhead is 
restored to its normal position and tension. This inflation should be 
carried out daily until the improvement obtained at each visit remains 
permanent until the next; then the time is lengthened to two, three, 
or four days or more, or a week or two between the treatments, accord- 
ing to this rule, until the cure is complete. As soon as the organ is 
apparently restored to its normal condition treatment should be dis- 
continued, as a retrogression may otherwise occur. Overtreatment is 
certainly to be avoided. At each sitting the inflations are repeated 
from two to four or six times, with not enough pressure to cause pain 
or bright redness of the membrana flaccida. The vessels along the 
upper portion of the handle of the mallet often become injected even 
after gentle inflation. 

For the removal of the fluid contents of the tympanic cavity that 
do not disappear after inflation, a number of years ago the author 
devised a method that he has never seen mentioned except once, 
which was in a journal article that appeared about three years follow- 
ing his publication. The patient inclines his head forward and a little 
toward the opposite side, and practices an experiment that just re- 
verses the Valsalvan method. He closes the nose with his thumb and 
forefinger and draws the air from the naso-pharyngeal space down 
into his throat. This method exhausts the air of the cavities above 
the pharynx and sucks the secretions from the Eustachian tube and 
middle ear into the throat; they can be seen immediately afterward 
trickling down the side of the pharynx from the region of the tube- 
orifice. When the drumhead was perforated I have utilized this same 
method to draw medicated solutions from the external meatus 
through the middle ear and tube into the pharynx or nose. This 
thoroughly washes these surfaces with the remedies u<ed. 

Many cases do not require the use of the catheter. The inflator 
(Fig. 134) will inflate the middle ear in almost every instance in 
which it is properly employed. This saves the patient suffering, pre- 
vents injury to the inflamed Avails of the tube, and avoids the possi- 



HYPERTROPHIC CATARRH OF THE MIDDLE EAR. 417 

bility of infection, as the inflator is not carried into contact with the 
mucous surfaces as the catheter is. 

If my method of auto-aspiration of the tympanic cavity through 
the Eustachian tube should not suffice on account of the thick, tena- 
cious character of the secretion, paracentesis of the drumhead should 
be made under antiseptic precautions, as already described in the 
treatment of acute inflammation of the middle ear. After opening 
the membrane, air is thrown through the tube and tympanum so as to 
eject all discharges from them into the external meatus. There need 
be no fear that any permanent damage may be done by the para- 
centesis, for it will undoubtedly close in a few days. The expelled 
secretions should be removed by cotton on a carrier and the canal 
left dry. The meatus is then closed with absorbent cotton. Should 
fluid accumulation recur the membrane may have to be reopened, 
even repeatedly in exceptional cases. A few days or weeks of this 
treatment generally suffice for a cure, but the more obstinate condi- 
tions require months for their eradication. 

The treatment for associated rhinitis and pharyngitis will be 
found under those headings. 

Medicinal applications may be advantageously employed when 
simple air-douches fail to reduce the tumefaction and hyperemia of 
the lining tympanic membrane. A number of years ago the author 
introduced the use of purified liquid vaselin, and later camphor-men- 
thol in lavolin, for treating tubal and tympanic catarrh. The physio- 
logical action of camphor-menthol is given in Chapter I. Sprays 
of these remedies are thrown into the tube and middle ear by means 
of the improved inflator. The sponges it contains are saturated with 
the liquid and, by applying the cut-off of the compressed-air tube to 
the inflator, a jet of the remedy is projected into the tube and tym- 
panum. I have since learned that Charles Delstanche, of Brussels, 
preceded me in the use of liquid vaselin in the middle ear. This 
treatment is usually best followed by the massage otoscope in obsti- 
nate cases. After the treatment has effected all that is possible we 
have observed that patients maintain their improvement and even 
continue to progress, after changing their residence from low and 
damp surroundings to a high, dry, and equable climate. 

Operations on the drumhead are treated of in Chapter XXXVII ; 
and hygienic measures are considered in the treatment of acute rhi- 
nitis, or coryza. 



27 



CHAPTER XXXVI. 
DISEASES OF THE MIDDLE EAR (Continued). 

Adhesive Inflammation of the Middle Ear. 

Synonym. — Sclerotic tympanitis. The term sclerosis is objected 
to by some writers, but it is retained because of our need of a brief, 
well-understood name. 

The line of demarkation cannot always be distinctly and un- 
mistakably drawn, between the early adhesive and the late hyper- 
trophic middle-ear catarrh. The latter may merge by imperceptible 
degrees in the adhesive variet}^ and the sclerotic processes may pass 
through their initial stage during the activity of the hypertrophic 
inflammation. But the most intractable forms of deafness — involv- 
ing ankylosis of the ossicles, especially immobility of the stapes, and 
labyrinthal involvement — characterize the adhesive, or sclerotic, ca- 
tarrh. 

Pathology. — While this form of catarrh may affect the whole 
lining membrane of the middle ear, it may be circumscribed and 
limited to the tissues surrounding the oval and round windows. A 
distinguishing characteristic is an insidious interstitial inflammation, 
induration, and chronic thickening of the tissues, or sclerosis. But 
in a considerable proportion of cases there is progressive atrophy; 
pale, thin membrane, and calcareous degeneration. Again, there may 
be an excessive proliferation of connective tissue, filling and even 
obliterating the cavity of the attic and of the oval and round fenestra 1 
and binding down the ossicles to such a degree as to impede or pre- 
vent their normal movements. Bands connecting the membrana tym- 
pani and ossicles together alter the normal tension of the conducting 
apparatus, resulting in varying degrees of deafness and perversion of 
hearing. These bands become the seat of calcareous degeneration, 
with the result of binding the ossicles to each other, to the mem- 
brana tympani, and to the tympanic walls with rigid or bone-like 
bridges. The drumhead is often the seat of these chalky deposits, 
which generally appear like miniature drifts of snow in crescentic 
forms below and about the mallet (Fig. 156 and Plate VIII). 
(41S) 



ADHESIVE IXFLAMMATIOX OF THE MIDDLE EAR. 



419 



Ankylosis of the ossicles takes place either by increased fibrous- 
tissue formation or by bony growth. Ankylosis is infrequent between 
the anvil and stirrup, but is frequent between the mallet and anvil, 
and between the stirrup-plate and the border of the oval window. 
Indeed, we may have these ankyloses combined with bands of adhe- 
sions binding the membrana tympani and ossicles together, and hy- 
pertrophy and calcareous degeneration of the membrane of the round 
window. The natural filaments and bridges of mucous membrane con- 
necting the crura of the stirrup with the border of the oval foramen 
(Fig. 157) favor the fixation of this bone when fibrous or calcareous 
changes occur. Calcification or ossification may take place in the 
ligamentous ring of the stirrup, and bony union with the oval window 
may result. Calcareous deposits have been found in the malleo- 
incudal joint, and I have suspected that in patients of a uric-acid 




Fig. 156. — Semilunar Chalky Deposit in Front of the Handle 
of the Mallet. (After Politzer.) 



diathesis deposits of urate of soda might take place in these joints as 
well as in other articulations. Eichey believes sclerosis to be closely 
related to progressive arthritis deformans. In a conversation with Pro- 
fessor Politzer upon this subject, the author asked him if he had ever 
discovered such a deposit, but he replied that he had not, since, in 
his method of preparing specimens, any evidence of such deposits 
would be destroyed. Christopher J. Colles believes that a rheumatic, 
gouty diathesis has undoubtedly much to do with the obstinate char- 
acter of many cases of middle-ear trouble, especially the chronic mid- 
dle-ear catarrh. 

"J. Habermann has observed that a slight degree of hyperostosis 
of the promontory and of the inner tympanic wall, leading to a posi- 
tive closure of the niche of the round window, is induced by a chronic 
inflammation of the middle ear." ("American Year-book," 1902.) 



420 



ADHESIVE INFLAMMATION OF THE MIDDLE EAR. 



The Eustachian tube may participate in a diffuse form of this 
inflammatory process and become stenosed, but it is often normally 
permeable and even abnormally patulous. 

Etiology. — The hypertrophic, or secretive, inflammation of the 
middle ear undoubtedly predisposes to the adhesive or dry sclerotic 
form. The latter is noticeably hereditary and can'be often traced to 
the father and his family or to the mother and hers. The brothers 
or sisters are often more or less afflicted. General diseases that are 
destructive of tissues and exhausting to the general strength promote 
this form of middle-ear catarrh. Chronic catarrh of the nose and 
throat and excessive indulgence in alcohol and tobacco-smoking bear 




Fig. 157. — Niche of the Fenestra Ovalis, with the Crura of the Stapes, 
in the Normal Ear of an Adult. (After Politzer.) Network of bands 
extending from the neck of the stapes to the walls of the niche, c, Head 
of the stapes, s, s, Crura of the stapes. 



a close causative relation to sclerosis. Yet the writer cannot place the 
emphasis on smoking that some authors do, since he has seen the 
worst examples of this disease in both women and men who were not 
at all addicted to the use of tobacco. 

The hypertrophic form might be spoken of as a disease of child- 
hood, during which it is very common; but sclerosis is a disease of 
middle and old age. In my experience it nearly always is seen in 
persons over 30 years of age, rarely in those younger, and usually in 
those much older. It generally affects both ears, and, although 
patients in the early stage often aver that only one ear is troublesome, 
the surgeon should never fail to examine both — and the naso-pharynx 
as well. 



ADHESIVE INFLAMMATION OF THE MIDDLE EAE. 421 

Symptomatology. — Tinnitus aurium constitutes the most dis- 
tressing symptom. Patients often declare that if the noises only can 
be conquered they will be satisfied, whether their hearing can be im- 
proved or not. These are variously described as high-pitched ring- 
ing, like that produced by quinine or by boxing the ears; like roar- 
ing or rushing of waters; chirping of crickets; hissing; the singing 
of a tea-kettle; escaping steam; sighing of the winds, etc. The in- 
tensity of the tinnitus is usually in proportion to the loss of hearing, 
until the miserable subject can hear little or nothing but the inter- 
minable storm of confusing and crazing noises, compared to which the 
clanging and crashing of the kettle-drums and cymbals in a Wag- 
nerian overture are a heavenly melody. 

The suffering is increased by cold, wet, and windy weather, tak- 
ing cold, alcoholic drinks, speaking or reading aloud, and anything 
that produces excitement or depression of the strength or spirits. 
Sometimes a startling loud sound rings out suddenly, without any 
apparent cause, like that produced by a stroke from a hammer on a 
high-pitched bell; then gradually it dies away until it is lost in the 
confusion of other less intense subjective sounds. Often patients de- 
clare that the noises are not in the ear itself, but refer them to the 
side of the head and even to the occiput. Most frequently, however, 
the author has noticed that they place the tips of their ringers over 
the hearing-centre in the brain when locating the sounds outside of 
the ear. They sometimes believe it is possible for others to hear these 
noises if the observers ear were to be placed close to their own. I 
have known some patients to insist that crickets or other creatures 
were in their ears, and that they must be 'removed, when the sounds 
were entirely subjective. 

On the other hand, persons with discipline of mind and strong 
will suppress mentally these besieging enemies of consecutive thought 
and intelligent action until they are scarcely conscious of their pres- 
ence while engaged in active occupations. But when the mind be- 
comes disengaged for a time in a quiet place, or more especially when 
there is occasion for listening intently to a speaker, the noises seem 
to surge back into the presence of the conscious mind with furious 
intensity. Very nervous individuals are so overwhelmed by this symp- 
tom that they may succumb and part with their reason. 

Severe or continuous pain is not a symptom of sclerosis, but 
sharp, stinging pains lasting but a few seconds or minutes are not un- 
common. Great sensitiveness to certain sounds and to concussions of 



422 ADHESIVE INFLAMMATION OF THE MIDDLE EAK. 

the air exists. The slamming of a door may be painful, owing to the 
noise or to the concussion, or both. With abnormal tension of the 
sound-conducting apparatus and impaction of the foot-plate of the 
stirrup in the oval window, there is an increase of labyrinthal pres- 
sure and more or less headache, vertigo, and sense of tightness or pres- 
sure in the head, although the patient may not be able to particularize 
or localize it unless he possesses a very observant mind. 

The hearing is generally much worse in sclerosis than in hyper- 
trophic catarrh, and shows less variation either with or without treat- 
ment. The hearing may vary during the day. One individual hears 
better in the morning and worse in the evening. Another hears 
better until, perhaps, 4 o'clock in the afternoon, when the hearing 
becomes dull, to remain so the rest of the evening. Another hears 
worse in the morning until he has his breakfast and boards the train 
for the city, when the jar of the car appears to produce a commotion 
in his ears, his Eustachian tubes open to the admission of air to the 
tympanic cavities, and at once he hears better and experiences a sense 
of clearness and relief in his ears. In the noise he hears better, even 
better in some instances than those with normal hearing. A locomo- 
tive engineer under my care said he could hear better than his com- 
panions when his engine was in motion, and that his employers, for 
whom he had worked several years, did not suspect his impairment of 
hearing. He managed to give them no opportunity of conversing 
with him except in a noise. The vibrations of his engine communi- 
cated motion to his conducting apparatus, which then conveyed sound- 
waves that were too feeble of themselves to institute movements. 

Another interesting fact has come under my observation. A 
long-standing catarrh of one ear had so impaired its usefulness that 
the patient did not consciously depend upon it. The better ear had 
lost its usefulness through an attack of epidemic influenza, when the 
patient was obliged again to depend on the previously worse ear. 
Then it was found that, although sounds could be distinguished in it, 
they could not be understood. Words could be heard, but not in- 
terpreted, on account of long disuse of the organ. It became ne* 
sary to practice with the various words in common use until they 
could be distinguished from cadi other and correctly interpreted. 
The process was comparable to learning a new language, but it was 
accomplished. 

In this case the sounds of the (' and C forks, L28 and 256 vibra- 
tions, were perceived by air and bone conduction at the correct pitch 



ADHESIVE INFLAMMATION OF THE MIDDLE EAK. 423 

by both ears. The C" and C", 512 and 1024 vibrations, were always 
heard at the proper pitch with the right ear, and by bone with the 
left ear; but by air with the left they were perceived as a half-tone 
above the real pitch. Fork C"", 2048 vibrations, was heard with each 
ear faintly, when almost touching the month of the meatus, but not 
by bone-conduction with either ear. The patient distinguished with 
difficulty between this fork and the subjective ringing, which was of 
the same pitch. 

The hearing for speech is the most affected, while hearing for 
music, etc., may remain fair. The musical composer, Emerson, was 
afflicted with greatly impaired hearing for speech; but he mastered 
the trying requirements of a great musical conductor. Hearing bet- 
ter in a noise, paracusis Willisii, is characteristic of this form of ear 
disease. By the simple expedient of causing sound-vibrations in the 
air by means of such a device as an electric hammer, or an electric 
bell with the gong removed, or a spring and ratchet in an electric 
motor or fan, one with this form of deafness may be able to conduct 
a business conversation when otherwise he could not without a con- 
versation-tube or horn. It is not, however, the commotion of the air 
produced by the fan-wings that aids hearing, but the sound-waves 
that keep the drum-membrane and ossicles in vibration. 

Bone-conduction is not so likely to be normal in this as in the 
hypertrophic process. It is often much diminished or altogether ab- 
sent for the highest and lowest notes. But it should not be forgotten 
that bone-conduction begins to show reduction after the thirtieth 
year. The hearing for the highest tones and the very low notes is 
diminished or lost in the order named. Certain notes in the median 
register may also be unperceived, which indicates labyrinthal im- 
plication. 

Diagnosis. — The appearances of the drumheads vary greatly. 
There are thickening and retraction of the membrane (Figs. 158 and 
159 and Plate VIII) with foreshortening of the mallet-handle in some 
cases (Fig. 155), while in others there is atrophy with chalky deposits, 
or, in other instances, a membrane of quite normal appearance. The 
adhesive process may be confined to circumscribed areas on the surface 
of the inner tympanic wall which inspection does not reveal. The 
Eustachian tubes may have been involved during the early stages, 
while later in the history of the disease they may be freely permeable. 
The massage otoscope will show any adhesion of the membrane to the 
inner wall (Fig. 160) and the amount of mobility that the mallet may 



424 



ADHESIVE IXFLAMMATIOX OF THE MIDDLE EAR. 



have lost. It will also reveal bands of adhesion that may exist super- 
ficially behind the drnm-membrane if the latter is pressed by the air 
inward so as to lie against and embrace these bands. When there is 
normal freedom of motion of the hammer during the massage, it is 
certain that its articulation with the anvil and the articulation of the 
latter with the stirrnp cannot be ankylosed; but the stirrup may be 
ankylosed in the oval foramen. In such cases, with a normal-looking 
drumhead, one must be very guarded in his prognosis, for they are 
sometimes intractable and hopeless. 

Prognosis. — From what has been said it will be naturally in- 
ferred that brilliant results may not be expected from treatment in 
a large proportion of cases of sclerosis of the middle ear. The out- 
look will be more favorable if the disease is not of long standing, if 
tinnitus is either absent or only an occasional symptom, if the hear- 
ing is not seriously impaired, if bone-conduction is normal, and if 




Fig. 158. — Marked Retraction of the Drumhead. (After Politzer.) 



treatment produce a decided amelioration of the symptoms. The 
reverse of these circumstances renders the prognosis unfavorable. 
Age, general health, sanitary surroundings, personal habits, heredity, 
and occupation must also enter into the account. 

Treatment. — We can hardly speak of treatment in this form of 
middle-ear cataiTh as being generally curative. We must candidly 
admit that in otology, as well as in other branches of medicine, there 
are cases that will sometimes baffle the most skillful practice of our 
art. All that we can hope to accomplish is to stay the progress of a 
persistent process. A patient who was formerly under my treatment 
said, when informed that he had lupus: "Then I will have nothing 
done." I replied: "If a wolf were biting you, would you not want 
me to take him off?" So in the present disease- it is our duty to in- 
terpose every possible obstacle to the development and progress of the 
pathological process thai is attended with Buch distressing and de- 



ADHESIVE INFLAMMATION" OF THE MIDDLE EAPt. 



425 



plorable results. If no more can be accomplished than to relieve the 
never-ending din of harassing noises that incessantly bombard the 
bram, it is worth the while. This confusing strife of discordant 
sounds, this concentration of all the overtones in nature focused on a 
sensitive being almost deprived of normal, intelligible, sweet-toned 
sounds, often test the tension of the mind to the breaking-point. 

The most common and simple treatment is the injection of air; 
but, in order to accomplish enough movement in the membrane and 
ossicles to stretch or break bands of adhesions and to overcome anky- 
losis, more force must be applied than is recommended in the simple 
hypertrophic catarrh. While the latter may require with a patulous 
tube no more than 8 or 10 pounds, or less, we have employed 60 
pounds and even more pressure without producing much impression 
on these old, hardened, thickened, leathery drumheads. This is not 




Fig. 159. — Circumscribed Depressions in the Antero-inferior Quadrant 
of the Left Drumhead. (After Politzer.) 



mentioned as an intimation to the unpracticed that they should use 
so much pressure, but 20 pounds' pressure is often required. in this 
affection to produce any motion in the ossicles. Wiirdemann advo- 
cates similar treatment, with the air-regulator. When the foot-plate 
of the stirrup is not ankylosed, some transitory giddiness may be oc- 
casioned by this pressure, but in case it is immovable we do not look 
for dizziness to occur from inflation. If we can obtain sufficient move- 
ment in the stirrup to produce momentary vertigo it brightens the 
outlook, for it probably indicates that bony union has not yet taken 
place between the base of the stirrup and the border of the oval 
foramen. If inflation and massage are followed by an amelioration of 
the symptoms, improved hearing, abatement of the tinnitus, relief of 
a sense of pressure, and a feeling of clearness in the head, then the 
prospect is encouraging. If a few weeks of daily treatment should 
make no perceptible impression of any kind, the opposite is true. But 



426 ADHESIVE INFLAMMATION OF THE MIDDLE EAR. 

the massage treatment on alternate days is a most important auxiliary 
to politzerization, and we can now profitably enter into its detail. 

The author's massage otoscope (Fig. 114) possesses some advan- 
tages over others. As compared with Siegle's pneumatic speculum, 
the author's otoscope is (1) self-illuminating, not requiring the aid 
of a hand-mirror or forehead-mirror, the light being accurately fo- 
cused on the drumhead; (2) it affords a magnified view of the field; 
(3) it can be operated in a smaller canal than will admit the specu- 
lum; (4) the bright reflection of light into one's eye by the glass of 
the speculum, the black background of which converts the glass into 
a mirror, is avoided in the otoscope by the proper and unvarying rela- 
tions and the color of its various parts. The directions for manipu- 
lating this instrument are given in Chapter XXIX. 

By alternately rarefying and condensing the air in the auditory 
meatus the amount of mobility in the drumhead and. the chain of 




Fig. 160. — Circumscribed Adhesion of the Membrana Tympani to the 

Promontory Underneath the Handle of the Mallet. (After 

Politzer.) a, Point of adhesion. 

bones may be determined under brilliant illumination and a magni- 
fied view. If ankylosis of the joints of the ossicles, or if bands of ad- 
hesions between the bones and the walls of the tympanum exist, the 
handle of the malleus will be seen to be impeded in its movements, or 
it may remain fixed, while the membrane about it may be quite 
flaccid, and respond to the rarefaction of air by bulging outward about 
the mallet-handle (Fig. 151). When the membrane is greatly thick- 
ened in patches or contains calcareous deposits, these portions will 
be seen to resist the action of the vibrating column of air, while nor- 
mal parts and areas of thin, cicatricial tissue that indicate the loca- 
tions of former perforations may respond readily to the experiment. 
In cases where the drumhead is very thick, or where the ossicles arc 
bound down by adhesions to the walls of the tympanum, no per- 
ceptible movement may be obtained at first, but decided improvemeni 
often follows a persistent use of the pneumatic treatment. 



ADHESIVE IXFLAMMATIOX OF THE MIDDLE EAR. 



427 



It is our usual practice to continue massage with the pneumatic 
otoscope not longer than from one-twelfth to one-third of a minute 
at a time. A longer massage may carry the stimulating effect on the 
circulation to the point of irritation or congestion of the drum-head. 
If the movements of the membrane are painful, the massage is dis- 
continued, and we never use this instrument during an acute otitis 
media. The patient must be warned against any movement of his 
head during the massage, since, if he jerk his head away from the 
instrument, it may produce a violent suction of the drumhead out- 
ward and result in pain, congestion, and rupture of blood-vessels. 
The discomfort of pressure of the rubber-tipped funnel should be dis- 
tinguished from pain caused by movements of the membrane and 
ossicles. 




Fig. 161. — The Intratympanic Masseur. 



As a counterpart to the massage treatment with the otoscope, the 
writer has practiced a method of intratympanic massage, for a long 
time, in the following manner: When innatino- the middle ear with 
air, vapors, or fluids, the air-current entering the inflator, vaporizer, 
or catheter is interrupted by means of operating the valve of the 
cut-off with the thumb. In this manner the current may be inter- 
rupted about three hundred times per minute, if desired. While the 
author never knew of this method being used by any other before him, 
it is quite natural to suppose that it has occurred to others, and for 
that reason he claims no priority to putting the principle into prac- 
tice. 

W. H. Weaver has devised an intratympanic vibrator (Fig. 161) 
which has given excellent results in the writer's practice. The cur- 
rent of air is interrupted by means of a wind-wheel, and it is attach- 



428 ADHESIVE INFLAMMATION OF THE MIDDLE EAR. 

able to the inflator, catheter, or vaporizer. (The Laryngoscope, Xo- 
vember, 1899.) 

"Suarez de Mendoza has found the application of pneumomassage 
to the ear for fifteen or twenty minutes at a sitting has the best effect 
upon tinnitus annum." ("American Year-book/' 1902.) 

In obstinate cases the progress may be hastened by making pres- 
sure directly upon the processus brevis by means of a probe covered 
with a soft-rubber tip or Lucars pressure-probe. Stiffness in the 
joints may be overcome in this way so as to facilitate the action of the 
otoscope. One should press gently on the process until the handle 
moves, then retract the probe until the malleus resumes its former 
position, press again, and so repeat the movement three or four times. 
Then the pneumatic principle of the otoscope should be applied until 
one is satisfied that the advantage gained will not be lost. The 
mallet should be moved until the patient experiences a sensation of 
movement or sound. The utility of passive motion, or massage, in 
the treatment of stiff joints and atrophied tissues is well recognized 




Fig. 162. — Lucae's Pressure-probe. 

in general surgery. The application of the same principle to the 
same conditions in aural surgery is also attended with beneficial re- 
sults. Charles Delstanche, of Brussels, has also invented an excellent 
massage instrument. 

The pressure-probe which I devised in 1886, and which was de- 
scribed at the meeting of the American Medical Association in 188S. 
has been superseded by a much better one (Fig. 162) invented by my 
good friend Professor Lucae, of Berlin. It consists of a delicate shank 
set parallel to its hollow handle by a right-angle deviation, so as to 
bring the operator's fingers out of the field of vision. The distal ex- 
tremity terminates in a cup lined with soft fibre that fits over the 
short process of the mallet. The handle contains a delicate spiral 
spring surrounding the proximal end of the shank so that pressure 
on the short process and release of pressure should produce a rebound 
or to-and-fro excursion of the hammer-handle without removing the 
cup from the process. This method is painful and causes congestion 
of the membra na fiaccida, but is often beneficial. Direcl pressure on 
the line of the short process is the most effective on the stirrup. 11 



ADHESIVE INFLAMMATION OE THE MIDDLE EAR. 429 

treatment by inflation and massage produce redness along the malleal 
plexus of vessels, and extending over the greater part of the mem- 
brana flaceida, it should not be used further during that treatment. 

We have found the best results from a systematic plan somewhat 
as follows: For the first week or two lavolin is injected into the mid- 
dle ear by means of the improved inflator (Fig. 134) on Monday, 
Wednesday, and Frida}^ always preceding the ear treatment with the 
necessary cleansing and medication of the nose and throat. On the 
intervening days the massage otoscope is used sufficiently to obtain 
as nearly as possible the normal mobility of the ossicles, or until the 
hyperemia, mentioned before, is produced. On the second or third 
week the treatments are gradually separated by intervals of from 
two to four days. The lavolin conduces to the softening and ren- 
dering pliable the adventitious tissues in the middle ear. When stim- 
ulation is desired, or the patient or surgeon is in doubt as to the en- 
trance of the jet of lavolin into the tympanic cavity, 6 or 10 drops of 
sulphuric ether added to the lavolin in the sponges contained in the 
inflator will produce stimulation and a sensation of coolness followed 
by a glow of warmth in the ear, thus demonstrating its presence in 
the tympanic cavity. Eichey advocates the iodine-vapor inflations 
and iodized cotton in the external canal. Dundas Grant uses a self- 
inflator charged with chloroform. 

If it should be desirable to produce the effect of camphor-men- 
thol on the lining membrane of the tympanic walls without carrying 
a perceptible amount of the menstruum into the cavity, this can be 
accomplished by substituting the vaporizer (Fig. 125) for the inflator, 
with a 3-per-cent. solution of camphor-menthol in lavolin. For the 
physiological action of camphor-menthol see Chapter I. It is but 
proper to remark that the beneficial results sometimes afforded by this 
method are even more surprising to the surgeon than to the patient. 

Formerly the author followed in the footsteps of his predecessors 
in the employment of vapor from resublimed iodine crystals with 
which to douche the middle ear, but so little perceptible good and so 
much irritation attended its use that it has had little place for this 
purpose in his practice for a number of years. Pilocarpine hydro- 
chlorate, in 1- and 2-per-cent. solutions, is much used for injections 
into the middle ear through the catheter. Generally 6 to 10 drops 
of the weaker solutions are injected three times a week for four or 
six weeks. The medicine and catheter must be sterilized, and used 
while warm. These injections are best alternated with the massage 



430 ADHESIVE INFLAMMATION OF THE MIDDLE EAK. 

treatment. The author has tried solutions of citrate of lithia, a very 
soluble form, by injections through the Eustachian tube, in the hope 
that if deposits of urate of sodium were present in certain gouty pa- 
tients, and if the ankylosis of the ossicles were due to the presence 
of this deposit as in other joints of the same individuals, it might be 
dissolved out. Carbonate of lithia is known to accomplish similar 
results. The effect was nil. 

A considerable variety of other solutions and volatile medica- 
ments have been projected into the middle ear for this form of ca- 
tarrh, but it would be a waste of time and space to enumerate most of 
them. Many are inert and others are positively harmful. The injec- 
tion of fluids through the Eustachian catheter and. tube is attended 
with irritation of the tube and tympanum unless accomplished by ex- 
ceptionally skillful and gentle hands — and no others should attempt 
it. Possibly a little tympanic irritation may prove beneficial, but the 
probabilities are in favor of its proving harmful. If hyperaemia is 
desired it can more easily and safely be produced by the prolonged use 
of the massage otoscope and Lucse's pressure-probe. 

The Valsalvan method produces congestion of the tympanic tis- 
sues, and for that reason patients ought not to be taught or allowed 
to practice it. They receive a certain amount of temporary relief; 
consequently they practice it not once or twice a day, but repeatedly, 
many times a day, until the membrana tympani loses its tension, be- 
comes relaxed and retracted, and no more relief is had. Such a case 
was lately under observation. He began practicing autoinflation ten 
years before coming under my care. He was advised by a prominent 
aurist to practice the Valsalvan experiment, and he has grown pro- 
gressively worse during all that time. It is an interesting incident, 
which should serve as a warning, that he had been under the care of 
three aural surgeons, two of whom are eminent, without the fact of 
his being addicted to this habit being disclosed. This is only one 
example of numerous instances which could be cited as illustrating 
the unwisdom of placing in the hands of patients methods for self- 
treatment that are likely to result in more harm than good. The 
sole fact that the patient was worse after ten years of autoinflation is 
not mentioned as proof that the retrogression was due to the practice. 
The opinion is based on the results of studies. of numerous cases, the 
details of which cannot be incorporated with this observation. 

The use of the phonograph, vibrometer, and other expensive in- 
struments that produce sound-waves of speech, or musical vibrations 



ADHESIVE INFLAMMATION OF THE MIDDLE EAR. 431 

that are combed to the ears by rubber tubes inserted into the ex- 
ternal canals, have been much vaunted by ill-advised laymen; but 
experimental investigation only confirms what a familiarity with the 
principles involved presages: their utter, inutility. During a discus- 
sion of this subject at the meeting of the First Pan-American Medical 
Congress, the otologists present, including the distinguished Professor 
Politzer, concurred in these conclusions quite generally. 

It is worthy of attention that the treatment with the improved 
inflator filters all the air and fluids before they reach the ear. All 
are forced through the finest quality of medicated sponges, which 
offer a resistance to the air-current of about four pounds. This fact 
should be given proper consideration in every treatment, and all the 
instruments must be kept scrupulously clean and sterilized in order 
not to commit the unpardonable sin of infecting a patient. A 5-per- 
cent, solution of carbolic acid is convenient for this purpose. 

Massage of the external meatus has been a part of the author's 
treatment for a considerable time, although he has refrained from 
mentioning the method until convinced of its undoubted value. After 
observing the beneficial effects of massage on other organs it oc- 
curred to me to try the effect of the application of the same prin- 
ciples to the external auditory canal in the atrophic condition accom- 
panying sclerosis. The result was not only that patients experienced 
a sensation of relief and freedom from itching, but the middle ear 
appeared to make better progress than when the massage was omitted. 

The method pursued is as follows: Cotton is twisted quite firmly 
on the slender silver holder (Fig. 115) so that it will not easily slip 
off; this is smeared with vaselin or a 5-grain yellow-oxide-of-mercury 
ointment made with vaselin; then the anointed cotton is rubbed or 
stroked upon the canal-walls in a circular direction while the holder 
is rotated on its axis in the direction that will prevent the cotton from 
becoming disengaged. This friction is continued only long enough 
to thoroughly cleanse the skin and stimulate the circulation. The 
ceruminous glands, which are generally in an atrophied state in this 
disease, are aroused to greater activity. The skin, which is dry, scaly, 
and often eczematous, assumes a healthier appearance, and the effect 
upon the process of nutrition does not appear to be confined to the 
external canal, but seems to extend to the tympanic cavity. 

Care must be taken to avoid touching or irritating the drum- 
head, and the cotton must not be allowed to slide off the end of the 
holder so as to allow the latter to abrade the skin. The author has 



432 ADHESIVE INFLAMMATION OF THE MIDDLE EAR. 

not seen this method pursued or suggested by others, yet experience 
deprives him of the temerity to advance the claim to originality or 
priority. 

How long shall treatment be given? Only so long as improve- 
ment continues. If treatment is protracted much beyond the time 
indicated, it may be followed by an actual retrogression. Too much 
treatment is pernicious. When improvement takes place and a state 
is reached in which the benefit remains stationary, despite all efforts 
for a reasonable time, then treatment had best cease. The patient 
should be discharged with proper instructions for the care of himself, 
and for his return should he begin to lose the gain already made. In- 
deed, these unfortunates must be gently, but candidly, informed that, 
so long as life's burden bears upon them, just so long they will suffer 
the necessity of repeating their journeys to the aurist whenever re- 
lapses occur. The invariable question "How long must I'be treated?" 
every otologist has to encounter. The average length of time re- 
quired varies from one to three months. Often the patient will 
remark that his head feels clearer and the noises have diminished or 
changed in character, which are favorable indications. If but one ear 
is affected, its early treatment may prevent the other from following 
in the same route. Or if both are affected, if they have not become 
too seriously involved, we may be able to arrest the progress of the 
disease and preserve, if not improve, the present state of hearing. 

The application of the faradic current for ten minutes at a time 
daily for several weeks has appeared to exert a beneficial effect in 
certain cases. I have designed electrodes (Fig. 188) adapted to the 
concentration of the current in the ears, because the older ones dif- 
fused the electricity over the side of the head. The tips of the 
chamois-covered electrodes are wet and covered with a little moistened 
cotton, inserted into the auditory canals, and buckled in place. Then 
the cables connecting the electrodes with the battery are attached. 
In this manner the patient is relieved of the tiresome holding of the 
electrodes in place. However, we do not attach great importance to 
electricity in this disease. 



CHAPTER XXXVII. 
DISEASES OF THE MIDDLE EAR (Continued). 

Opekative Treatment oe Tympanic Adhesive Inflammation. 

The author has devised an ossicle-vibrator (Fig. 163) for the pur- 
pose of breaking up adhesions in the middle ear and ankylosis of the 
ossicles. It consists of a shaft of steel armed with two little levers at 
the distal end, and fashioned at the proximal extremity to fit into the 
angular handle of the middle-ear instruments. It is used in the fol- 
lowing manner: An incision is made through the drumhead close 
to the anterior border of the hammer-handle and parallel with it from 
the short process to its tip under cocaine anaesthesia. Then the end 




Fig. 163.— The Author's Ossicle-vibrator. 

lever, which is curved for the purpose, is carried through this slit and 
behind the mallet, when the handle falls between the two little levers. 
They are then slipped along upward, embracing the handle, until the 
stronger part of the bone is reached and the levers fit the handle some- 
what closely. Now the retracted hammer-handle is slowly and very 
gently drawn upon until it is felt to move, or until the adhesions are 
felt to give way, and to the extent of bringing the handle to its nor- 
mal position. The gentlest care must be taken or the adhesions may 
give way very suddenly with a jerk and the mallet might possibly be 
dislocated, or the handle might be fractured, especially if the instru- 
ment were allowed to slide downward upon the weaker portion of the 
handle. We have not known these accidents to attend the use of 
this instrument, but one can conceive that they are within the range 
of possibilities. Again, a patient has become pale just as the adhe- 
sions yielded to the traction, and nearly fainted. This was probably 
due to the disturbance of the intralabyrinthal fluid as exaggerated 
motion was effected in the stirrup. Some most remarkably beneficial 

28 (-133) 



434 TKEATMENT OF TYMPANIC ADHESIVE INFLAMMATION". 

results have followed the use of this simple method of mobilization of 
the ossicles. No harm has "been known from it. After making the 
incision and before introducing the vibrator, it conduces to the com- 
fort of the patient to instill a few drops of a warm 8-per-cent. cocaine 
or eucaine solution. 

Incision of the posterior fold of the drumhead is indicated when 
there is a great sinking inward of the membrane, with foreshortening 
of the mallet-handle, and exaggerated prominence of the short proc- 
ess, with a stretched appearance of the membrane about it. This con- 
dition, associated with serious impairment of hearing, and head 
noises that are unimproved by the treatment already detailed, calls 
for this simple operation. The section is best made about midway 
in the folds (Fig. 164) and the knife (Fig. 167, No. 2) is made to cut 
from above downward, with care that it is not carried deeper than is 




Tig. 164. — Section of the Posterior Fold of the Membrana Tympaili. 

(After Politzer.) 

required to sever the fold. Otherwise the chorda tympani (Fig. 165) 
may be severed, producing paralysis of taste. Although the author 
has made such sections frequently, he has never known this to follow, 
but such results are reported. Patients generally observe a sense of 
relief from pressure, clearness in the head, diminution of subjective 
noises, and sometimes improvement in the hearing. In the class of 
cases in which we have principally practiced this operation we have not 
been able to follow up the results for years, but have known the bene- 
fit in a few to persist for several years. In others of a worse type the 
improvement has been transient. 

Multiple incisions of the drumhead have proven beneficial in 
some instances. In 1886 the author reported the results of a series of 
cases to the meeting of the American Medical Association, from which 
we quote: "For the purpose of making a crucial test of the efficacy 
of this procedure, the writer 'has made it the last resort in those that 



TKEATMENT OF TYMPANIC ADHESIVE INFLAMMATION. 



435 



afforded no real hope for relief from any other treatment. Perhaps 
the propriety of operating on those patients that seemed to promise 
no results might be questioned, were it not for the fact that in nearly 
all of them there was an unexpected improvement and that no un- 
fortunate consequences followed the operation. The cases chosen 
to operate on were far more hopeless than those with chronic sup- 
purative inflammation. The consideration that the former respond 
so little to our efforts, while the latter are so amenable to treatment 
with inflations, cleansing, peroxide of hydrogen, boric acid, bichloride 




Fig. 165.— Internal Surface of the Left Membrana Tympani. (After 
Politzer.) a, Head of the malleus. b, Neck of the malleus, c, Tendon of 
the musculus tensor tympani and anterior fold of the membrana tympani. 
d, Inferior extremity of the handle of the malleus, e, Anterior portion of 
the membrana tympani. f, Chorda tympani and posterior fold of the 
membrana tympani. g, Incus, li, Short process of the incus, i, Long 
process of the incus. 



of mercury, etc., with the result of not only arresting the disease, but 
of improving the hearing, has led me to seriously reflect upon the 
advisability of establishing the suppurative process in sclerotic inflam- 
mation of the middle ear. In a few cases only in my practice has this 
condition followed the procedure under discussion, and the results 
in the series of cases reported were satisfactory, especially when it is 
considered that they were the most unpromising and had proven the 
most intractable to the usual methods of treatment. But, as re- 
marked above, this experimental work, which was carried out princi- 



436 TREATMENT OF TYMPAXIC ADHESIVE INFLAMMATION. 

pally in dispensary practice, did not afford opportunities to trace the 
results for a number of consecutive years. The simple incision, of 
course, closed in a few days, but the tension of the drumhead appar- 
ently was restored to more nearly the normal." Subsequently one of 
these cases came under my observation, showing that the really bril- 
liant results obtained by this method had persisted for twelve years. 

Another method that the writer has since pursued with consider- 
able success was the excision of areas of the drumhead, usually tri- 
angular in shape (Fig. 166). Under cocaine triangular flaps were 
made with the apex above, then the attached base was severed, remov- 
ing this piece of the membrane entirely. It was sometimes easiest, 
after incising the two sides of the triangle, to grasp the apex with 
delicate forceps in one hand while the base incision was made with the 
other. The improvement in some patients in whom there was no 
labyrinthal disease was very gratifying, and in private patients the 




Fig. 166. — Triangular Resection of the Drumhead. (After Politzer.) 

possibility of maintaining the aperture for a considerable time was 
demonstrated. In one instance it had remained open a year and a 
half when the patient removed from the State. A peculiar experience 
was had with the other ear. The first operation afforded so much im- 
provement that he requested that the same operation be performed on 
his right ear. It was done, and a slight, muco-purulent discharge fol- 
lowed, but soon ceased. While the discharge lasted, the hearing was 
considerably improved and the tinnitus relieved. After the discharge 
ceased the hearing began to diminish, when he expressed regret that 
the ear had not continued moist. This led me to anoint it with warm, 
pure vaselin, but when it was removed a few days afterward the very 
large perforation was entirely closed with cicatricial tissue. 

The removal of sections of the drum-membrane may prove other- 
wise advantageous. It affords accessibility to the tympanic cavity for 
the instillation of various remedies and the destruction of the adhe- 



EXCISION OF THE MEMBRANA TYMPANI AND OSSICLES. 437 

sions., and it reveals whether the entire resection of the drumhead 
would improve the hearing. In case the membrane is so thickened 
and sclerosed and infiltrated with calcareous deposits as to preclude 
the possibility of its responding to any except extraordinary sound- 
waves, and the labyrinth is not involved, the opening of a window 
in the drumhead will admit sound to the stirrup and to the round 
window and prove whether the entire absence of the membrane would 
prove remedial. If the adhesive process has not ankylosed the stirrup 
in the oval window nor invaded the round window, vibrations can 
reach the labyrinth if the barrier to their admission be removed. The 
writer has employed this test to determine whether excision of the 
entire drumhead would afford successful results. 

Division of the tensor tympani tendon is not much in favor 
among American aurists. The indications for it are not very clearly 
defined, and the appearances that suggest the shortening of this 
muscle — retraction of the membrana tympani and foreshortening of 
the mallet-handle — are also just as characteristic of the presence of 
membranous folds and bands of adhesion. The results of tenotomy 
have been either so unsatisfactory or so positively detrimental that 
the operation is not encouraging. Greene and Pomeroy operate pref- 
erably with a blunt-pointed knife curved on the flat to sever the 
tensor tympani. 

EXCISION" OF THE MEMBRANA TYMPANI AND OSSICLES. 

This operation for ankylosis is a subject concerning which there 
is probably less unanimity of opinion among otologists than upon any 
other. While a few American aurists, especially Burnett, Sexton, 
Blake, and Jack, have been enthusiastic advocates of the operation, 
and some others have followed their lead for a time, the majority ap- 
pear to have receded to a more conservative position. At the meet- 
ing of the section of Otology at the Tenth International Medical 
Congress, in Berlin in 1890, the Continental leaders in this specialty 
expressed themselves in very conservative terms on the subject. Sev- 
eral years ago the writer, through the columns of the Journal of the 
American Medical Association, invited all who had performed this 
operation to communicate the results to him for the purpose of pub- 
lishing a collection of experiences that would afford a just estimate of 
the average value of this operation. The responses were so few and 
so unsatisfactorv as to force the conclusion that the operation was 



438 EXCISIOX OF THE MEMBRAXA TTMPANI AND OSSICLES. 

either little practiced or was disappointing. There is probably little 
or no diversity of opinion concerning the utility of the operation in 
suppuration of the middle ear, especially when there is ossicular 
necrosis; but as practiced for ankylosis there has been so much divi- 
sion of opinion and sad, disappointing experiences reported during the 
past few years that candor requires that the subject be treated with 
reference to the ill as well as the good results. A number of cases 
have been under my observation upon whom the operation has been 
performed by surgeons both East and West, with the effect of pro- 
ducing a suppuration of the middle ear, destroying the hearing, ap- 
parently intensifying the noises, and producing more or less vertigo. 
The writer has had under treatment a physician from a far-western 
State whose ossicles were removed from one ear by a noted aural 
surgeon ten years before. All the ill results enumerated followed 
the operation, and, although the hearing was two inches for the watch 
before the operation, that ear has been totally deaf ever since, and 
the opposite ear has seriously deteriorated. This is a fair type of 
numerous similar instances that have come to my personal knowledge, 
and under the observation of other physicians who have been kind 
enough to report them to me. 

Out of six cases operated upon by a young aurist, and reported 
by him at a recent meeting of Western specialists, the results were 
unfortunate in four. In one, which was under observation a number 
of months before, the operation was followed by total deafness, san- 
guino-purulent discharge, and facial paralysis that treatment failed 
to benefit. 

B. M. Behrens (International Medical Magazine. May, 1897) re- 
ports his experience as follows : "Up to the present time the radical 
operation of removing the drumhead and malleus has been performed 
on 34 cases, of which 30 have given very little improvement or none 
whatever." 

Wurdemann had the courage to report several similar results at 
the meeting of the American Medical Association in 1892. It is 
worthy of mention that nearly all of these unfortunate cases were 
operated upon by specialists in eye and ear diseases: so that the 
results cannot be attributed to a wain of familiarity with the subject. 
It is not our purpose to inveigh against this procedure as an opera- 
tion, but to emphasize the necessity not only of the utmost precision 
and gentleness in operating, but also the most painstaking prelimi- 
nary examination and experiments to determine the possibility or 



0PEEATI0N" FOE EXCISION OF THE OSSICLES. 439 

otherwise of beneficial results. For example, if the hearing-tests 
demonstrate that the labyrinth is involved in the disease, the inutility 
of the operation is established. If no improvement follow a resection 
of a portion of the drumhead so as to admit sound-waves to the 
fenestra leading to the internal ear, no help can be expected from 
excision of the whole membrane. We do not lose sight of the fact 
that, b}^ removing the drum-membrane and the two larger ossicles, 
we are afforded access to the stirrup so as to mobilize it. Some ad- 
vantage certainly is to be conceded to this measure, although mob- 
ilization of the stirrup is not as simple an act as one might believe. 
Even with every vestige of the membrane removed, the stirrup is 
situated so high that a good view of it is difficult to obtain, and it 
is easy to dislocate when it is not ankylosed. 

QPEEATION FOE EXCISION" OF THE OSSICLES. 

The ear should be prepared by syringing with a warm solution 
of bichloride of mercury, 1 to 1000, and the instruments should be 
immersed for three minutes in boiling soda-water. For several years 
past the author has used ether to the exclusion of chloroform, in- 
structing the ansesthetizer to administer only so much as is absolutely 
necessary to secure quiet and freedom from suffering. Cocaine anaes- 
thesia is not as effective as ether. After removing debris of any nature 
from the canal, it is dried and closed with absorbent cotton until the 
operation commences. If ether is used, the patient must occupy a 
recumbent position. We have found it convenient to use tables of 
sufficient height to bring the patient's ear opposite the eyes of the 
operator while the latter is sitting (Fig. 206). A brilliant illumina- 
tion is needed. We have generally used the Argand gas-lamp and light- 
condenser (Fig. Ill) or the sixty-candle-power incandescent gas- 
burner. One will have a clearer view of the field of operation if the 
room is darkened so that no light penetrates the operator's eye except 
that reflected from the ear-cavity. 

The instruments necessary (Fig. 167) are a paracentesis-knife 
(No. 2); a blunt-pointed bistoury (No. 1); two angular knives, right 
and left (Nos. 4 and 5); two ossicle-hooks, right and left (Fig. 168); a 
pincette (Fig. 169); a dozen slender cotton-carriers armed with cot- 
ton; a quart of hot, sterilized water, and a syringe. 

The operation proceeds as follows: The drumhead is incised 
with knife No. 2 near the periphery, behind the short process of the 



440 OPERATION FOR EXCISION OF THE OSSICLES. 

mallet. Into this opening the blunt-pointed knife (Xo. 1) is inserted 
and carried first below, then sweeping the lower and the anterior at- 
tachments until the roof is reached; then this attachment is severed 
until the whole circular incision is completed, ending at the first 
entrance. The knife is best carried first from above downward, for 
the reason that less haemorrhage is likely to obstruct the view than 
if the more vascular membrana flaccida were first cut. There is less 



r 



-i 7a 5 



«« nMnii i 

^-■■— -■ --t in ii n -- ■ ■ - -■> 2 



— "" ; rinMi ' -^ I 




Fig. 167. — Middle-ear Instruments and Handle. 

haemorrhage also if the knife is kept a little way from the periphery 
of the membrane. Now the angular knife is used to separate the 
articulation of the anvil and stirrup (Fig. 170). The anvil is extracted 
by aid of the hooked probe, and the attachments of the mallet are 
then divided, when it is brought away with the pincette. Stacke de- 
taches the auricle and removes the integumentary canal first. 



A. 



Fig. i68.— The Author's Ossicle-hook. 



The operation is a very short one, requiring but a few minutes 
ordinarily if there is not much haemorrhage or if the adhesions are 
not embarrassing. Rapid use of the cotton-carriers, which should be 
kept prepared by a nurse, will keep the field quite clear; but in case 
of considerable bleeding the syringe and quite hot, sterilized water 
or suprarenal extract can be used. It is difficult to avoid severing the 
chorda tympani in this operation, but the resulting paralysis of taste 
is of short duration. The ear-cavity should be dried after bleeding 



OPERATION" FOR EXCISION OF THE OSSICLES. 441 

has ceased, covered with a layer of aristol from the small powder- 
blower (Fig. 144), and the canal closed with iodoform gauze. While 
there is considerable reaction in some cases, followed by discharges of 
a nmco-pnrulent character^ in others there is little or no disturbance. 
The patient should be kept quiet, and his diet restricted until healing 
takes place. By properly regulating the diet, both before and after 
the operation, there is less tendency to regeneration of the drumhead. 
The latter occurrence is quite frequent. In the case of the physician 
I have mentioned there is a false drumhead which we have not re- 
moved, for the reason that no possible good could come of it. 

In another case of a very robust man from Kansas the writer 
removed the third adventitious membrana tympani, at his request. 
In the spring of 1893 a surgeon had removed his drumhead and 




Fig. 169.— Politzer's Pincette. 

mallet. In seven days after the operation he says the drumhead had 
been reproduced. This was removed, and in seven days more the sur- 
geon said that another had closed the tympanum. A third operation 
was had, and in fourteen days another drumhead had formed. Two 
years afterward the patient came to me with the request that this 
remaining fourth drumhead with which nature had supplied him 
be removed. He suffered from great tinnitus and uncomfortable 
sensations of pressure, etc. Examination revealed labyrinthal in- 
volvement and the procedure was advised against. But, notwith- 
standiug the assurance that no improvement was to be expected, the 
patient insisted upon the operation, with the hope that it might afford 
some relief to the tinnitus and pressure-symptoms. Therefore I re- 



442 



OPERATION FOR EXCISION OF THE OSSICLES. 



moved the drum-membrane and anvil at the Post-graduate Medical 
School and Hospital, June 21, 1895, and cauterized the periphery of 
the drumhead so as to completely destroy the whole circular attach- 
ment. A few days afterward I found the stirrup dislocated, and re- 
moved it. No unfavorable symptoms followed; the membrane has 
not been reproduced, and the slight discharge following the operation 
soon ceased. The ear has remained in good condition ever since, but, 
although the patient imagined himself better, I could discern no im- 




P h b d c I ) 



Fig. 170. — Vertical {Section of the External Meatus, Membrana Tym- 
pani, and Tympanic Cavity. (After Politzer.) a, Cellular spaces in the 
superior wall of the meatus connecting with the middle ear. b, Roof of 
the tympanic cavity, c, Inferior wall, d, Tympanic cavity, e, Membrana 
tympani. f, Head of the malleus, g, Handle of the malleus, h, Incus. 
i, Stapes, k, Fallopian canal. I, Fossa jugularis. m, Apertures of 
glands in the external meatus, n, Inferior wall of the osseous meatus. 
o, Short process of the mallet, p, Fissures in the cartilaginous meatus. 
r, Junction of cartilaginous and osseous portions of the meatus. 

provement. The tinnitus and other symptoms were neither removed 
nor considerably improved. The patient thought he could hear, but 
accurate tests proved the contrary. This case is instructive in showing 
that thoroughly electrocauterizing the peripheral attachmenl of the 
membrane will prevent its regeneration. We do not often employ ibis 
cautery in the ear on account of the great heat generated in such a 
minute inclosed space, but other caustics have too superficial an effect 
to accomplish the purpose. 

The reference to these unfavorable cases— and I might cite 



MOBILIZATION OF THE STIRRUP. 443 

others who have come under my care, one of whom was the most dis- 
tinguished of American editors — is not for the purpose of condemning 
the operation itself, fori believe that these unfortunate results are at- 
tributable either to an unwise selection of cases or to unforseen acci- 
dents attending the operation. For example: Why should two inches 
of hearing for the watch be exchanged for total deafness, vertigo, etc. ? 
"What could have happened to cause destruction of the facial nerve? 
The results point toward an injury to at least one of the fenestra? 
opening into the labyrinth. But the reverse of this picture presents 
excellent and even brilliant results. Some cases that have proved 
intractable to the usual measures have yielded to this; but these are 
the ones in which the labyrinth has not been involved, and the adhe- 
sive process has not.destro} r ed the usefulness of the stirrup and the 
membrane of the round window, and in which excision of a small 
section of the membrana tympani would demonstrate the possibilities 
of the operation. Barclay, Sexton, Burnett, Blake, and Jack favor 
excision of the ossicles. Gleason severs the incudo-stapedial articula- 
tion to improve the hearing in adhesive inflammation. 

Mobilization of the stirrup has been practiced with favorable 
results, especially by Jack; but the crura of the stirrup are so 
exceedingly delicate and fragile that they are quite likely to break on 
applying side-pressure to them or on traction with the hook. This 
manoeuvre is not in favor with otologists generally. After the 
membrana tympani has been removed for ankylosis the conditions are 
most favorable for mobilization. The probe can then be introduced 
alongside the stirrup and pressure exerted in all directions to break 
up adhesions and effect mobility. The hook can then be engaged in 
the apex of the converging legs of the bonelet and drawn upon until 
slight motion is had. But if the adhesion give way suddenly, the 
stirrup will be dislodged or extracted unless great care is exercised. 

Excision of the ossicles for persistent suppuration is a common 
practice, especially in the case of caries and necrosis of these bones 
or of the walls of the tympanic cavity. Great cleanliness must pre- 
cede these operations, which can more easily be performed under 
eucaine or a 20-per-cent. solution of cocaine than in dry catarrh. 
The writer has often operated under these anesthetics without any 
difficulty, especially when the patients were possessed of considerable 
self-control. The same instruments and methods are employed as in 
the operation for ankylosis. If much curetting of the bone is neces- 
sary, a general anaesthetic (ether) had better be used. 



4:44 STAPEDECTOMY. 

Keferring again to sclerotic inflammation of the middle ear, out 
of twenty-two cases of stapedectomy reported by Blake there was 
only one improvement, and in this the fixation of the stapes was not 
complete. Some became worse after the operation, both as to hearing 
and tinnitus. In five cases vertigo came on and persisted. Stapedec- 
tomy is now disapproved of by Blake, Cozzolino, and Gelle. 



CHAPTER XXXVIII. 

DISEASES OF THE MIDDLE EAR (Continued). 

Chronic Suppurative Inflammation of the Middle Ear. 

Synonym. — Chronic suppurative tympanitis. 

This is a common sequel of acute suppuration and full of im- 
port to the afflicted patient. While the laity, and unfortunately cer- 
tain members of the medical profession who are not well informed 
upon the consequences of the disease, minimize its importance and 
advise that it be let alone and that children will outgrow it, the pa- 




Fig. 171. — Extensive Destruction of the Drumhead. (After Politzer.) 

tient's life may pay the penalty of its neglect. The disease may out- 
grow the patient. The close relations of the tympanic and cranial 
cavities ought to suggest to the mind of every thoughtful physician 
the importance of prompt and skillful interference with the pro- 
gressive destructive ravages of a suppurative process. It is not self- 
limited; it does not tend toward resolution, but toward dissolution, 
and no trifling makeshift is pardonable. 

Pathology.— The whole tympanic cavity is usually affected, the 
mucous membrane being hypertrophied and reddened, or yellowish 
and leathery in appearance. It seems unnecessary to remark that a 
perforation in the drumhead always exists, and in cases of long stand- 
ing the opening is likely to be quite large and to afford some view 
of the interior of the cavity (Figs. 171 and 172 and Plate VIII). 

The membrana tympani is rarely completely destroyed, and in 
those instances in which the destruction is quite extensive (Fig. 173) 

(445) 



446 



CHRONIC SUPPURATIVE INFLAMMATION OF MIDDLE EAR. 



the membrana flaccida usually remains. The rupture of the mem- 
brane takes place most frequently in the lower posterior or anterior 
quadrant, but may be found in ShrapnelPs membrane, — a very un- 
favorable location with reference to drainage. If the perforation 
appear above the short process of the mallet, we suspect necrosis of 
this bone. The instances are not infrequent in which the whole lower, 




Fig. 172.- — Pear-shaped Perforation of the Drumhead. (After Politzer.) 

or tense, membrane is destroyed, while the loose membrane from the 
short process upward is intact. The hammer-handle projects down- 
ward, free from any membrane except perhaps a border on each side 
of the upper half of the handle (Figs. 174 and 175). This gives an 
excellent view of the inner wall of the cavity and of the long leg of 
the anvil and possibly the leg of the stirrup if they are present. 




Fig. 173.— Perforation of the Posterior Half of the Right Drumhead. 
(After Politzer.) Behind the mallet is the projecting, yellowish-gray 
promontory; above it the long cms of the incus lying free and the pos- 
terior crus of the stirrup. 

When the ossicles participate in the necrotic process, the anvil 
is the first to succumb in three-fourths of the cases. This is to be 
accounted for by its poorer blood-supply. Its nutrition is easily cut 
off by pressure in the upper part of the tympanum. 

In long-standing suppuration, and more especially when the de- 
struction of the drumhead is extensive, there occurs a shedding of 



CHRONIC SUPPURATIVE INFLAMMATION OF MIDDLE EAR. 447 

superficial epithelium of the middle-ear membrane, which takes on 
an epidermic character; so that it presents the appearance of skin 
rather than mucous membrane. This probably is brought about by 
an extension or growth inward of the epidermis of the canal through 
the perforated membrane, and cholesteatoma may result. 




Tig. 174. — Destruction of the Inferior Half of the Membrana Tympani, 

Laying Bare the Promontory and Xiche of the Round 

Window. (After Politzer.) 

While the perforations of acute suppuration generally close spon- 
taneously after the discharge ceases, they more often remain more or 
less permanently open after the chronic suppuration is cured. In a 
long course of suppuration the destruction of the membrane is far 
more extensive than in the acute or transitory variety. Yet we often 



H8K 


mil 

r i&Sk. ^M 


IMf 

I ill 





Fig. 175. — Large Perforation of the Right Drumhead. (After Politzer.) 

The handle of the mallet is free and the long eras of the 

incus and the niche of the round window are yisible. 

come upon elderly people who show unmistakable evidences of ex- 
tensive loss of tissue of the membrane that has been repaired by 
nature — large sections in the lower posterior or anterior quadrant, or 
in both, that consist of translucent, thin, cicatricial tissue, surrounded 
by the ashy-gra3 r , leathery tissue of the old membrane. Many of these 
people are unconscious of ever having had a discharge from the ear, 



448 CHRONIC SUPPURATIVE INFLAMMATION OF MIDDLE EAR. 

but upon investigation the fact may be established that it occurred 
beyond their remembrance, probably during childhood. 

The disease may extend to the labyrinth, although it is not of 
frequent occurrence. It far more often invades the mastoid antrum 
and cells. If we recall the position of the antrum behind the middle 
ear, and the connection of these cavities by the aditus ad antrum, 
and then their relative positions when the patient lies upon his back, 
we shall appreciate how the fluids in the tympanum may drip through 
the aditus and enter the antrum (Fig. 220). It is like the changing 
of the battery-fluid from one part of a Kidder tip-battery cell to the 
other by turning the cell upon its axis. It is apparent from these con- 
siderations that mastoid disease is a logical consequence of middle- 
ear suppuration. 

Etiology. — From what has already been said it is evident that 
this affection is only an extension of the acute suppurative process 
in most instances, the causes of which are enumerated in Chapter 
XXXV. Neglect of an acute disease generally results in a chronic 
one. A tubercular or syphilitic habit of body predisposes to this con- 
dition. 

Symptomatology. — The presence of a purulent discharge issuing 
from a perforation in the drum-membrane is a simple matter to dis- 
cern. The pus may be abundant or very scant. The author had 
under treatment a case of more than twenty years' standing in which 
not more than a drop or two exuded in a day. For a few days or a 
week there would be no discharge, and then a foul-smelling exudation 
was found. In other instances there is not enough purulent discharge 
to run out of the canal, but instead it dries in scales or yellow crusts 
on the walls of the canal. As these crusts of inspissated pus work 
toward the mouth of the canal they cause itching and consequent 
annoyance. 

The hearing may not be seriously impaired. It does not de- 
teriorate so genera] ly nor to such a degree as in sclerosis. Still, the 
hearing is greatly affected in occasional cases. Crusts may form over 
a small perforation, obstructing the discharge and impairing hearing; 
but patients do not often complain of subjective noises. 

Granulations (page 456) often form on the border of the perfora- 
tion and over the surface of the intratympanic membrane (Fig. 176 
and Plate VIII). Large, cherry-red, spongy ura nidations sometimes 
may cover the inner wall like a cushion. They are sensitive and bleed 
readily. 



CHROMIC SUPPURATIVE INFLAMMATION OF MIDDLE ' EAR. 449 



Polypi (page 456) occasionally spring from the membrane and 
occupy the canal. A single polypus often fills the canal and extends 
to its mouth. We have seen them grow to such proportions that the 
pressure upon the canal-walls interfered with the circulation in the 
end projecting from the mouth of the canal to the extent that its 
color was livid or black and suggestive of gangrene. We also have 
multiple aural polypi of luxuriant growth and of the form of a min- 
iature cauliflower. These are usually of a bright-red color. If the 
pus in which the polypus is macerating is carefully removed without 
irritating the polypus, the latter presents sometimes a very pale, ex- 
sanguinated surface, but upon friction it assumes a bright-red color 
and bleeds upon being touched. Mucous polypi are more commonly 
met with than the fibrous variety. 

Carious bone (page 457) is to be suspected whenever granula- 
tions or polypi exist. The bent probe (Fig. 177) may detect denuded 




Fig. 176.— Destruction of Inferior Half of the Drumhead. (After Po- 
litzer.) Globular granulations on the inner wall of the middle ear. 

bone in the tympanic cavity. The anvil (Fig. 189) is occasionally lost, 
and, if the external wall of the aquseductus Fallopii, containing the 
facial nerve, is imperfect or necrosed, facial paralysis of the same side 
will occur if the pressure is sufficient, or the nerve itself may par- 
ticipate in the inflammation. William Sotier Bryant calls attention 
to the fact that there is sometimes a perforation in the outer bony 
wall of the aqueduct, establishing a direct communication with the 
middle ear. If necrosis of bone is present, the odor of the discharge 
is generally offensive, even when care is taken of cleanliness. With 
neglect of the discharge it may become very foul, even when there 
is- no osseous necrosis. Invasion of the labyrinth is ushered in by 
sudden dizziness, deafness, and nausea. Fortunately this is a very 
rare complication. 

Diagnosis. — If the description given be borne in mind, there is 
no difficulty in deciding upon a case of chronic suppuration of the 



450 CHRONIC SUPPURATIVE INFLAMMATION OF MIDDLE EAR. 

middle ear. The long-standing discharge from a perforation in the 
drumhead makes the case clear. 

Prognosis. — This is a progressively destructive disease. Its tend- 
ency is not to spontaneous resolution. While many attacks may 
appear to get well of themselves, as long as the diseased condition 
remains, just so long recurring attacks will succeed each other. With 
every fresh cold, back comes the flux. The disease continues, though 
no discharge ma}^ make its appearance for a time, and the patient is 
lulled into a false sense of security. A slight exciting cause sets up 
another exacerbation of the existing inflammation. Moreover, the 
natural tendency of this trouble is toward the bone. The mucous 
membrane of the middle ear answers the purpose of a periosteum, and 
the intimate relation of these structures jeopardizes the integrity of 
the osseous tissue when destructive processes are going on in the 
membranous lining. It has also been shown that mastoid suppura- 
tion is an offspring of middle-ear inflammation. The same may be 
said of phlebitis and sinus-thrombosis, meningitis, subdural abscess, 

' — f HiTI-lf*" * 



Fig. 177. — Slender Middle-ear Probe. 

pyaemia, and abscess of the brain. Only with proper treatment is 
the prognosis good. 

Treatment. — More brilliant results are obtained here than in the 
adhesive catarrhal form of inflammation. The first object is absolute 
cleanliness. This is best obtained by syringing the ear with at least 
a quart, or more if necessary, of sterilized water, or mercuric bichlo- 
ride solution, 1 to 5000, as warm as is comfortable to the patient. 
Unless a considerable quantity is used, all of the inspissated, greasy 
accumulation often found in a neglected suppurating ear is not re- 
moved. As much force as can be easily borne is generally required at 
the first cleansing, to remove all the discharges from the ear. The 
water ueed not be thrown with so strong a current as to produ.ce 
giddiness or nausea. The continuous-flow syringe, like the alpha 
(Fig. 143) ? is the most satisfactory, as it admits of mosl perfect control 
over the temperature of the water and the force of the current. The 
stream is directed a little toward the roof of the canal, rather than 
directly in a line with its axis, so as to return along its door. The 
patient, if an adult, can hold some conveniently shaped receptacle 
pressed closely against the side of the neck just beneath the lobule 



CHEOXIC SUPPURATIVE INFLAMMATION OF MIDDLE EAE. 451 

to catch the returning solution. The water once injected into the ear 
must under no circumstances be reinjected. We have found people 
(physicians!) committing that act. Crusts, inspissated pus, and ceru- 
men not expelled by the water can be removed with cotton on the 
carrier or a blunt probe. Delstanche has devised a tympanic syringe 
to inject the attic. The writer has found the antrum irrigator (Fig. 
64) very effective in washing out the attic and dislodging choles- 
teatomatous masses. 

After cleansing thoroughly with the syringe, the ear is inflated 
(Fig. 134) so as to eject any possible secretion remaining in the Eusta- 
chian tube or middle ear. The parts are then dried with absorbent 
cotton, and a coating of aristol or nosophen (page 410) is dusted over 
the surface of the middle ear with the small powder-blower (Fig. 144), 




Fig. 178. — The Author's Large Powder-blower for Use with a 
Hand-bulb or Compressed Air. 

or boric acid with the large powder-blower (Fig. 178). Aristol is ex- 
cellent on account of its antiseptic, anaesthetic, and cicatrizant prop- 
erties. It never causes pain and does not interfere with the hearing 
by clogging the canal or impeding the movements of the drumhead 
and ossicles. If the discharge does not show perceptible decrease in 
the course of a week or two, it is advantageous to substitute boric- 
acid for the aristol or to throw a coating of boric acid over the aristol 
dressing. This can be done without dislodging the latter, for it sticks 
tenaciously to the surface of the tissues. This adds the drying effect 
of boric acid to all of the excellent qualities of aristol, and consti- 
tutes an ideal treatment for such individuals as we have mentioned 
who have an idiosyncrasy against boric acid. We have met a few 
such instances with this disease, although they are oftener encoun- 
tered among the acute cases. After the first few treatments of this 



452 CHRONIC SUPPURATIVE INFLAMMATION OF MIDDLE EAR. 

kind it is advisable to resort to an entirely dry method, relying on 
the absorbent-cotton driers, inflation, and the powders, for cases 
often do much better with the dry than with the wet method. The 
discharges often cease after a few treatments, and occasionally after 
the first one. The results of painstaking methods are more surprising 
to the surgeon than to the patient, who may have been harassed for 
long years with annoying discharges. 

One of the most effective methods consists in packing iodoform, 
or nosophen, gauze quite firmly against the suppurating surface if 
it can be reached, more especially upon a granulating surface. If the 
iodoform disagree, other medicated or sterilized gauze must be sub- 
stituted. The dressings must be frequently repeated when the dis- 
charge is copious. 

Many other remedies are commonly used, but it is the author's 
purpose to give only what years of experience have proven to be the 
most efficacious and to inform the practitioner upon the relative 
merits of those that have been given extensive trials. Some will be 
mentioned merely for the purpose of saving the reader's time in ex- 
perimenting with the useless. 

Iodoform in fine powder is useful when the odor of the discharge 
and other signs indicate the presence of dead bone; otherwise it is 
not preferable to aristol or nosophen, and its disgusting odor is usu- 
ally very objectionable to fastidious people. The old-time remedy, 
silver-nitrate solution, was formerly extensively used in my clinics, 
but for years we have employed it but little. Having tried it in solu- 
tions varying in strength from 1 per cent, to a saturated solution, it 
became apparent that its remedial qualities in this disease were in- 
ferior to remedies that were less objectionable. The blackening of 
everything it touches renders it especially disadvantageous in private 
practice. Zinc sulphate exerts too little influence to merit our con- 
fidence. Salicylic-acid powder, highly recommended a few wars ago. 
has proven, in my hands, a total failure in this disease. Moreover, 
the violent irritation of the nose and the attacks of sneezing which its 
unavoidable inhalation produces during the insufflation would pre- 
clude the possibility of its employment were it not otherwise im- 
potent. Europhen proved unsatisfactory in tin's disease. We have 
persisted in experimentation with it alone and combined with aristol. 
and are forced to the conclusion that the total value of europhen- 
aristol lies in the latter ingredient. Indeed, the aristol alone is more 
potent. After extended trials with yellow pyoktanin no appreciable 



CHRONIC SUPPURATIVE INFLAMMATION OF MIDDLE EAR. 453 

effect could be observed in arresting the discharge, and the same is 
true of dermatol, alumnol, and iodol. 

Let us suppose now that we have a more intractable type of sup- 
puration. The mucous membrane lining the tympanic cavity appears 
very reel, suggestive of the glow of dull red-hot iron; it is much 
thickened and tumefied; the drumhead partakes of the same char- 
acteristics, is very sensitive to the touch, and shows rhythmical pulsa- 
tions. These characteristics obtain in a small proportion of old cases. 
It is difficult to adapt the dry method of treatment to such condi- 
tions, for the touching of the drum-membrane with the cotton to 
absorb the discharges is productive of great pain. It is best then to 
irrigate and allow all the water to run out; then hydrozone, which is 
a stable 30-volume dioxide, or peroxide, of hydrogen (H 2 2 ), is 
warmed slightly, only sufficiently to make it comfortable to the ear, 
and is used to Jill the canal while the head is inclined to the opposite 
shoulder. Or, better still, the patient lies upon the opposite side. 
Warming the dioxide to the temperature of the body, or even ten 
degrees above, does not impair its efficacy, as we have often demon- 
strated. It is allowed to remain in the ear until effervescence ceases. 
This requires about five or ten minutes, according to the amount of 
pus present and the purity of the remedy. It must not have a strong 
acid reaction or it will cause pain, and it should contain not less than 
fifteen volumes of available oxygen. The hydrozone decomposes pus- 
corpuscles, during which action free oxygen is liberated to exert its 
germicidal property upon bacteria. Besides this the active efferves- 
cence that takes place dislodges the accumulations, and its mechan- 
ical action brings to the surface materials that even syringing fails to 
dislodge, — for example, aristol that may have remained from a pre- 
vious treatment. This boiling out of the middle ear appears to cleanse 
the attic even better than the intratympanic syringe, and no un- 
pleasant results have ever attended my use of it. 

After removing all of the debris which has been dislodged by the 
hydrogen dioxide, the ear should be dried with tufts of absorbent cot- 
ton. Then a 12-per-cent. solution of carbolic acid in glycerin is in- 
stilled and allowed to remain in the ear about ten minutes. This 
penetrates deeply, disinfects, deodorizes, and anaesthetizes the tissues 
sufficiently to permit of its being replaced with a saturated solution 
of boric acid in alcohol, without producing pain. 

The latter solution is particularly indicated when granulations 
are present, to shrink them. When this solution is allowed to run 



454 CHROXIC SUPPURATIVE INFLAMMATION OF MIDDLE EAR. 

out, after remaining ten minutes or more in the ear, the boric acid 
which remains on the suppurating surface should not be removed. 

F. C. Hotz reports excellent results from camphoroxol and men- 
tholoxol. The}' consist of combinations of hydrogen dioxide and al- 
cohol with camphor in the first instance, and with menthol in the 
second. The writer can confirm this report. 

E. B. Gleason prefers a 5-per-cent. solution of protargol, which 
"is an astringent and antiseptic quite unirritating to the middle-ear 
mucous membrane." (The Laryngoscope, March, 1900.) 

In suspected retained discharges in the attic or mastoid antrum, 
especially when the perforation is too small to admit of free drainage, 
it should be enlarged, as already described on page 406. But there 
are frequent instances in which the discharge does not diminish after 
thorough efforts at cleansing, disinfecting, and medicating. This 
may be due to the fact that the means employed do' not remove 
all of the retained secretions, and there is a consequent failure of the 
medicaments to reach all of the diseased surfaces. 




Fig. 179. — The Author's Ear-aspirator. 



The author has devised an instrument to meet this condition. It 
consists of an improved miniature airpump (Fig*. 179), containing a 
metallic valve that does not get out of order, fitted to a glass reservoir. 
The metallic tip of the reservoir should be covered with a section of 
soft-rubber tube so as to permit of its being fitted with firmness and 
nicety into the external meatus. Gentle traction on the piston-ring 
exhausts the air in the middle ear and accessory chambers and causes 
the ejection of any discharges within them into the canal, whence 
they are removed with the cotton absorbent. After the piston is 
moved the whole length of the cylinder once or twice the instrument 
is removed and the canal inspected. Then, after drying it of the se- 
cretions brought to view, the process is repeated two or three times. 
When no more discharges can be drawn from the hiding-places, it is 
safe to conclude that all have been evacuated. The traction need not 
be rapid nor strong enough to occasion discomfort or the exudation of 
any blood; although, if the latter occur, no harm is dene, for the 
discharges are the more thoroughly swept away and tin 1 tissues are 



CHRONIC SUPPURATIVE INFLAMMATION OF MIDDLE EAR. 455 

stimulated. The instrument is held in such a way as to grasp both 
airpump and receiver in the fingers of one hand at the same time, 
so as to prevent their being separated while the pump is in action. 
In order to prove the value of this simple device in numerous cases 
we have given the most thorough treatment by the old methods with- 
out diminishing the discharges, and then have resorted to this treat- 
ment in addition to the old methods, with the result of stopping the 
flux promptly. In such cases, after cleansing as much as possible by 
syringing, the use of dioxide, etc., we have applied the aspirator and 
have drawn an astonishingly large quantity of discharges that must, 
judging from their amount and character, have been stored in the mas- 
toid antrum and cells, and these cases have recovered without mastoid 
operations. In some instances we have drawn out large masses of 
thick, cheesy deposits that were not within the range of vision before 
using the aspirator. 

McBride opens the mastoid process and middle ear to cure 
chronic suppurative inflammation, and Jones advocates excision of 
the ossicles. 



CHAPTER XXXIX. 
DISEASES OF THE MIDDLE EAR (Concluded). 

Sequels of Middle-ear Suppuration. 

granulations. 

The presence of granulations (Plate VIII) in the middle ear or 
on the drumhead protracts the cure of a suppurating process. If they 
are small and not very extensive, they can be made to shrink up and 
disappear by the use of alcohol and boric acid. At first it is advisable 
to dilute the alcohol one-half. In the event of no pain being caused 
by that it can be used stronger, and if the patient easily bear it the 
full strength should be employed. The period in the treatment for 
using it is just after the cleansing process is finished, and the alcohol 
should remain in the ear ten minutes or longer. After it runs out 
the granulations that appeared very red before its application are 
blanched to a pale-gray color after the contact with the alcohol for a 
sufficient length of time. Then the treatment should be completed 
with the powders, as described in Chapter XXXVIII. Tincture of 
iodine is effective when applied to the granulations by the cotton- 
carrier, only enough being used to touch each granulation, but not to 
run over the surrounding surface. When the granulations are very 
large and abundant, suggestive of beginning polypi, these are best 
removed by the curette (Fig. 191) under a warm, 20-per-cent. solution 
of cocaine or an 8-per-cent. solution of eucaine. The bleeding is 
stopped by pressing a pledget of cotton against the curetted surface 
for a few minutes, a few drops of cocaine solution is used on them, 
and then the alcohol as before. Chromic acid may also be employed 
as described in the next paragraph. In my experience the ear has 
seemed to be intolerant of the presence of suprarenal extract. 

POLYPI. 

Two forms of aural polypi occur: the mucous and the fibrous. 
Suppuration cannot be cured so long as a polypoid growth is present. 
This is best removed under cocaine or eucaine by a polypus-forceps 
(456) 



CARIES AND NECROSIS OF THE MIDDLE EAR. 457 

(Fig. 180) or the snare found in the middle-ear case (Fig. 181). It 
requires less skill to use the forceps. The polypus should be detached 
as close to the attachment of its pedicle as possible, and, the method 
being so simple and identical with the same procedure in other fields 
of surgery, it would be superfluous to enter into the details here. The 
bleeding ceases soon and can be stanched as described in treating of 
granulations. Then cocaine is applied and the attachment cauterized 
with chromic acid. The loop of the flexible caustic applicator (Fig. 
182) is dipped into the dry crystals of chromic acid, and these are 
held over a small flame for a few seconds until they are melting. 
Just at the instant the crystals are fused in the form of a drop on the 
most convenient site of the loop for application the instrument is 
withdrawn from the heat and the drop of fused acid is blown upon 
to cool it suddenly into a bead. Unless the attachment of the polypus 




Fig. 180. — Politzers Polypus-forceps. 

is well cauterized it is likely to grow again. It can be removed with 
a fenestrated curette of good size, like the larger one in the middle- 
ear set, by placing the curette so as to engage the pedicle in the 
aperture. Then, by pressing firmly against it and drawing outward, 
it is detached and extracted. 

CARIES AND NECROSIS OF THE MIDDLE EAR. 

When the tympanic walls are denuded of their lining membrane, 
which is, in effect, its periosteum, the treatment requires much 
patience and persistence. After cleansing by water, hydrozone, and 
the aspirator, as already outlined, a 12-per-cent. solution of carbolic 
acid in glycerin is poured into the ear. This does not require warm- 
ing. After it has remained long enough to produce the anaesthetic 
effect of the acid — about six minutes — it is removed and replaced by 
a saturated solution of iodoform in alcohol. If the solution is agitated 



458 



CARIES AXD NECROSIS OF THE MIDDLE EAE. 



so that some of the powder is held in suspension, so much the better, 
for when the solution is allowed to run out after five or ten minutes 
a fine coating of iodoform powder is left covering the diseased tissues. 
This solution penetrates the diseased cavities deeply. Then the treat- 
ment is completed, as already described, for suppuration. In cases 




Fig. 181.— The Author's Middle-ear Case. 

where denuded bone could be felt with the probe, this method has 
effected cures. Indeed, sequestra of necrosed bone may have been 
cast off and discharged with the pus, leaving the healthy bone to 
become healed over by granulation. But if dead bone "be present it 
acts as a local irritant similarly to a foreign body, and must be re- 
moved with the curette before healing will take place. A foul odor, 



Fig. 182.— The Author's Caustic Applicator on Flexible Shank. 

notwithstanding scrupulous cleanliness in the treatment, indicates 
the presence of osseous necrosis. As long as this foul odor continue* 
the discharge cannot be stopped, but the disappearance of the odor is 
a very favorable symptom, and indicative of a cure. Persistence in 
this treatment will often remove the odor and discharge. There are 
occasionally persons with whom the alcoholic solution of iodoform 



NECROSIS OF THE OSSICULA. 459 

does not agree. The integument of the canal becomes swollen, ten- 
der, and excoriated, and the toxic iodoform must give way to other 
remedies. The bichloride of mercury occasionally is not well borne, 
and if used in too strong; a solution a similar condition ensues, and 
even ulceration of the integument. 

NECROSIS OF THE OSSICULA. 

The anvil, the first to yield to the necrotic process, is sometimes 
lost before patients apply for treatment, but when it is present and 
is diseased it should be removed. The same is true of the mallet. In 
such cases they are of no value to the patient, and only serve to ex- 
cite a continuation of the inflammatory process and to hinder the 





W0; 


^^S^^^v ~ 3 


Ilk 


* fes 




k 






V 

i 
i 





d 



a o 

Fig. 183. — Vertical Section of Middle Ear; Drumhead in Contact 
with the Inner Wall. (After Politzer.) a, Ledge-shaped remnant of the 
membrane. J), c, The lateral portions of the cicatrix, extending from the 
remnant of the membrane to the inner wall of the tympanic cavity, d, 
Portion of the cicatrix applied to the inner wall. 

free evacuation of the retained secretions. Their excision, if skill- 
fully accomplished, does not impair the hearing and may conserve it. 
The question of their removal in this instance is not a parallel case 
to that in sclerosis. The operation is described in Chapter XXXVII. 
Adhesions of the remnant or of cicatrices of the membrana 
tympani to the inner wall of the tympanic cavity may occur after the 
suppuration is cured (Fig. 183). The latter lesion results in a cup- 
shaped depression in the drumhead. Adhesions and false membranes 
also form within the tympanum, subdividing it into several cavities 
(Fig. 184). Connective tissue and chalky deposits (Fig. 185 and Plate 
VIII) sometimes completely fill the middle ear, imbedding the chain 
of bones so firmly that their functions are entirely destroyed. In case 



460 



PERFORATIOXS OF THE DRUMHEAD. 



the adhesions cause serious impairment of hearing by embarrassing 
the vibrations of the ossicles or by preventing sound-waves from 
reaching the labyrinth, they can be divided or excised. Connective- 
tissue formations and cretaceous deposits can be treated like choles- 
teatomatous masses, which are considered later. 

PERFORATIONS OF THE DRUMHEAD 

Perforations (Plate VIII), if they are large, generally remain 
open and require no treatment. The edges become covered with a 
continuation of the epidermis of the drumhead. The membranous 
lining of the middle ear becomes habituated to the presence of air 
that reaches it directly through the meatus, so that it acquires a 
tolerance for it, like the nasal mucous membrane. The hearing re- 
mains better with than without the perforation, but there are ex- 




Fig. 184. — Band-like Cords between the Lower End of the Hammer-handle 
and the Stapedo-incudal Articulation. (After Politzer.) 



ceptional instances in which the hearing is improved by closing the 
perforation with cotton or a thin rubber disc. The latter exceptions 
can be treated bv freshening the edoes of the perforation after the 
discharge ceases, and covering the aperture accurately with a moist 
disc of sized paper. The presence of this foreign body will excite 
sufficient irritation to increase the circulation in its vicinity to the 
extent of causing a proliferation of cells, growth of granulations, and 
consequent closure of the opening. But the cases are rare in which 
the patient's interest is best subserved by closing the perforation, for 
the remainder of the drumhead is usually opaque, hypertrophied, or 
calcified (Fig. 185) and leathery; so that it is unfitted !'<>r transmitting 
sound-waves. With an opening through it the "vibrations have direct 
access to the foot-plate of the stirrup and the membrane of the round 
window, and through them reach the perceptive apparatus. 



DEAFXESS FOLLOWIXG SUPPURATION. 



461 



Artificial drumheads should receive mention in this connection. 
"We have seen a few persons who believed they were able to hear bet- 
ter with discs or cones of soft rubber inserted so as to lie in contact 
with the membrana tympani; but the remote ill effects more than 
counterbalance the immediate apparent increase in hearing-power. 
When there is suppuration they impede the outward flow and pro- 
mote decomposition of the discharge. In any event, they act as for- 
eign bodies, giving rise to irritation and resulting increase in con- 
nective-tissue formation. This increased thickening of the tympanic 
tissues insures a still greater decrease in hearing. 

DEAFXESS FOLLOWIXG SUPPURATIOX. 

Deafness following suppurative inflammation calls for treatment 
after the suppuration ceases. Politzerization to overcome adhesions 




Fig. 185.— Central Perforation of the Drumhead and Calcareous 
Deposits. (After Politzer.) 

between the ossicles or drumhead and the walls of the tympanum 
may be practiced three or four times a week. Better still, if the per- 
foration has closed, is the method of throwing a spray of lavolin into 
the middle ear with the improved inflator (Fig. 134). The lavolin 
takes the place of the discharge, and it is commonly observed that 
the hearing is better while the middle ear remains moist. The 
lavolin is a bland, non-irritating liquid vaselin, and does not become 
rancid like oil. It softens the dried and hardened tissues, increases 
their suppleness, and promotes greater freedom of mobility. This 
injection is followed by the use of the massage treatment (Fig. 114). 
The drumhead is caused to make a score or more to-and-fro ex- 
cursions, with an endeavor to approximate as nearly as possible the 
natural limits of movement. This is after the fashion of the ma- 
chinist, who first oils his machine and then works it. This method 



462 CHOLESTEATOMA. 

is best pursued on alternate days for three or four weeks, or as long 
as perceptible progress is made in improvement, and then discon- 
tinued. As long as the benefit obtained is stationary the ear had best 
be let alone. It is well to instruct these patients that when retrogres- 
sion sets in they should return for further treatment. 

Tinnitus aurium is not a very common symptom in purulent 
inflammation, but it is an occasional sequel of that trouble. The 
treatment just detailed for the deafness is the best adapted for the 
subjective noises also. 

CHOLESTEATOMA. 

In this disease there is an excessive growth of epidermis in the 
external auditory canal and desquamation of epithelial cells in the 
middle ear. Lumps of epidermis and shiny, pearl-like, little masses 
are found, both during and after suppuration. Bezold believes them 
to be the result of an extension of epidermic formation from the ex- 
ternal canal to the middle ear. Lueaa reports a case without any 
suppurative process. Virchow believes they are true heteroplastic 
tumors. 

The epidermis of the external meatus spreads over the walls of 
the middle ear, and even invades the mastoid antrum, but the latter 
is the result of excessive proliferation of epidermis accompanied with 
exfoliation.- The concretions are of a caseous appearance, containing, 
besides epithelial cells, fat-globules, bacteria, and crystals of eholes- 
terin. 

The mastoid process is more often the seat of these masses than 
the tympanic cavity. They increase to a large size as the bone is 
destroyed either by advancing caries or necrosis or as the result of 
absorption due to pressure. 

"J. Habermann concludes that a long-continued discharge of 
pus into the external auditory canal and retention of this secretion 
in this passageway lead to a chronic inflammation in the epidermis 
and excessive formation and exfoliation of the horny layers. Another 
reason for the development of cholesteatoma in the ear is the chronic 
inflammations of the bone of the external auditory canal and in the 
middle ear, conditions which induce a copious supply of blood in the 
ear and a consequently better nutrition of the Malpighian layer, and 
increase in the number of its cells.*" ("American Year-hook," 1902.) 

The diagnosis is not difficull if the excessive formation and < : 
quamation of epidermis are noticeable in the external meatus, and 



FACIAL-NERVE PAEESIS AXD PAEALYSIS. 463 

if the epidermic masses are visible in the middle ear through a per- 
foration. Chunks of foul-smelling, gritty, cheesy particles may be 
found in the washings from the ear. The perforations are most likely 
to be found in ShrapnelFs membrane, for the growth of epidermis in- 
ward is marked on the upper wall of the canal. Long-continued and 
obstinate suppuration is characteristic of this disease. The masses 
constitute a dam against the free exit of the discharges, and decom- 
position of pus and the growth of polypi are encouraged. . This con- 
dition forms a fruitful soil for the propagation of bacteria. 

When the cholesteatoma is situated in the tympanic attic or in 
the mastoid antrum the diagnosis is difficult, if not impossible, to 
determine, unless the masses disintegrate and are evacuated during 
the cleansing treatment, or unless the mastoid cortex breaks down 
and exposes the condition present. If the diagnosis can once be posi- 
tively made out, the question of operative measures is settled. The 
methods of treatment are found under the headings of ''Chronic Sup- 
puration" and "Mastoid Operations. 7 ' Bezold advises epidermic trans- 
plantations in cholesteatomatous cavities, after the Thiersch method. 



FACIAL-NERVE PARESIS AXD PARALYSIS. 

Impairment or loss of function of the facial nerve is due to a 
variety of causes. The facial canal and neurilemma may participate 
in a middle-ear inflammation; ulceration and necrosis of the bone 
may involve the nerves an exudate, a callus, a sequestrum, or a tumor 
may produce pressure; sy^pliilitic or other central nervous disease may 
exist at the origin of the nerve, or traumatic injury may partly or 
wholly paralyze it. The lower branches supplying the nose, side of 
the face, and angle of the mouth are generally more affected in paresis 
from the mastoid operation than the upper branches that are dis- 
tributed to the orbicularis palpebrarum. But in some cases the fore- 
head and face are for a time seriously affected, even when the eye can 
be closed completely, but slowly, and with an effort. 

The same side of the velum palati may be involved in the paraly- 
sis. If the muscles of the side of the face and angle of the mouth 
are paralyzed, the patient cannot drink liquids without their drivel- 
ing from the lips, nor inflate the cheeks without the air escaping 
from the paralyzed corner of the mouth; in laughing the face is 
drawn to the unaffected side, giving a crooked appearance to the 
countenance (Fig. 186). The facial expression is entirely lost on the 



464 



FACIAL-NERVE PARESIS AXD PARALYSIS. 



side that is paralyzed. The inability to close the eye exposes it to 
winds, sunlight, and dust, resulting in chronic conjunctivitis. 

Eecovery may be expected from paresis due to an acute inflam- 
mation of the Fallopian canal and the sheath of the facial nerve 
secondary to the middle-ear inflammation, and from slight injuiies 
to the nerve during mastoid operations (Fig. 187). Paralysis, or com- 
plete loss of conduction of the nerve, resulting from caries or necrosis 
of the facial canal, or from division of the nerve during an operation, 




Fig. 186.— Facial Paresis. Appearance the same as in permanent facial 
paralysis. The patient is photographed while laughing. 

presents an unfavorable prognosis. In this condition the eye cannot 
be closed. 

Dench says: "Injury to the facial nerve is not a serious acci- 
dent, function being restored in from three to five weeks, in most 
cases, under the use of the faradic current." The author is not in 
accord with this view. If the whole calibre of the nerve-trunk is not 
affected, but only certain bundles, spontaneous resolution may occur 
and complete restoration of function in three to six months; but the 



FACIAL-NERVE PARESIS AND PARALYSIS. 



465 



author has never seen a case of complete recovery take place after 
total paralysis of all its branches had occurred from injury to the 
nerve during an operation. He has seen varying degrees of inter- 
rupted transmission in the different branches of the nerve, with corre- 
sponding variations in the recovery. The eye being the least and the 
side of the face and mouth next least affected would recover com- 
pletely, while the occipito-frontalis muscle remained powerless, giv- 
ing a noticeable drooping effect to the eyebrow. 




"Fig. 187. — Same asFig. 186, Three Months after Stacke Operation and 
Treatment with Electricity. 



On the other hand, we have had cases of paresis, affecting all the 
branches, occurring after operations for excision of the ossicles 
through the meatus, etc., recover completely after the use of the 
galvano-faradic current for three or four months. But we must make 
the distinction between paresis, or partial paralysis, and actual paral- 
ysis, which is a complete loss of nerve integrity. 

In the course of the nerve which is most exposed' to traumatism 
during the mastoid operation the bundles distributed to the orbicularis 
oris, the muscles of the side of the face, the occipito-frontalis, and the 



30 



466 FACIAL-NEKVE PARESIS AND PAEALYSIS. 

corrugator supercilii seem to lie externally to the fibres composing 
that part of thp. anterior temporal branches that supply the orbicularis 
palpebrarum, for the latter muscle is the least affected in operative 
paresis and the first to regain its function. 

Treatment of facial paresis and paralysis depends upon the lesion 
present. If the latter is an acute inflammation with exudation, upon 
the subsidence of the inflammation and the absorption of the exu- 
date recovery takes place. If there be pressure of the pus on an 
exposed nerve in midclje-ear suppuration, or if a sequestrum of 
bone produce the pressure, it must be removed. If syphilis is the 
cause, iodides and mercurials must be employed on general principles. 
Sexton mentions facial paralysis due to dental irritation. 

These cases recover after a course of the iodides, pilocarpine, and 



Fig. 188. — The Author's Ear-electrodes, Attached to a Head-band. 

electricity, the current being used from the primary coil of a faradic 
battery. The negative pole is applied to the ear of the affected side 
by means of an ear-electrode (Fig. 188), and the positive to the op- 
posite ear or mastoid region, then to the groups of affected muscles, 
causing perceptible, though not painful, contractions in them. Such 
a treatment should be given three or four times a week, continuing 
ten minutes. This prevents muscular atony or atrophy, while the 
nerve regains its tone. 

After the mastoid operation the electric current can be applied 
•directly to the injured section of the facial nerve by saturating a 
pledget of absorbent cotton with sterilized water or hydrogen dioxide, 
placing it in the bottom of the wound, and connecting the ear-elec- 
trode directly with this. The other polo is then applied to the trunks 
of the several branches of the nerve distributed to the groups of mus- 



CARIOUS PROCESSES IN THE TEMPORAL BONE. 467 

cles affected. If one is not familiar with these points he can readily 
determine them by applying the facial electrode to the opposite side, 
observing what areas need to be touched in order to contract the 
desired muscles. In Fig. 223 No. 1 shows the point where the elec- 
trode will affect the infra-orbital, malar, and temporal branches of 
the facial nerve. These supply the muscles of the forehead, the 
orbicularis palpebrarum, and the muscles of the face, nose, and upper 
lip. No. 2 shows the point where the electric current will reach the 
buccal and supramaxillary branches distributed to the buccinator and 
orbicularis oris and muscles of the lower lip and chin. 

CARIOUS PROCESSES IN THE TEMPORAL BONE. 

These do not characterize a large percentage of the cases of mid- 
dle-ear suppuration. They are sometimes due to tuberculous and 
other constitutional taints. While very small areas are likely to be 
affected, they may extend to involve the whole temporal bone. Scar- 
latina is one of the most frequent causes, but syphilis and typhoid 
fever may also give rise to them. The pneumatic portion forming the 
mastoid process is the most often affected. Xext in frequency come 
the tympanic walls and adjacent tissues. The anvil and sometimes 
the head of the mallet are attacked by the necrotic process. 

Pain is a pretty constant symptom of caries except in tuberculous 
individuals, the amount of pain being determined by the extent of 
periostitis or interference with the free discharge of pus. Other dis- 
tressing symptoms in addition to pain characterize this condition: 
dizziness, noises, nausea or vomiting, insomnia, and fever. The dis- 
charge is disgusting, often bloody and irritating. Granulations and 
polypi are commonly found, and the ossicles may be dislocated so as 
to wash out when the ear is syringed, together with sequestra of dead 
bone (Fig. 189). The meatus may be involved, — swollen or ulcerated. 
If the disease attack the inner tympanic wall, the external wall of the 
Fallopian canal may be destroyed, exposing the facial nerve to pres- 
sure or to the inflammatory process, resulting in facial paresis or 
paralysis of the same side. 

Exfoliation of the cochlea takes place in rare instances. Richey 
reports two such cases. Goldstein, in a very interesting communica- 
tion on the subject, reported a case of exfoliation of the cochlea, 
the vestibule, and the semicircular canals. A fair degree of hearing 
for conversation with the affected ear remained. Later Euedo, of 
Madrid, reported a similar case with retention of hearing. 



468 



CARIOUS PROCESSES IN THE TEMPORAL BOXE. 



Toeplitz has reported a case of primary labyrinthal necrosis with 
facial paralysis and deafness from scarlet fever. During the sup- 
purative process two sections of the cochlea were exfoliated and re- 
moved through the external auditory canal. 

The diagnosis of necrosis or caries is not an easy affair unless it 
can be seen or felt. The probe may detect it if within reach, but 
the diseased bone may be defended by a growth of granulations form- 




Fig. 189. — Sequestra of Dead Bone, and the Ossicles. Actual Size. 
(Author's Specimens.) The smooth surfaces of the walls of the tympanic 
cavity and of the meatus are shown in Nos. 1, 2, 3, 4, 5, 6, and 11. 13, 
Mallet. 14, Anvil. 15, Stirrup. 



ing a more or less complete carpet. Great caution is required in 
probing so as not to displace the little bones or open up the labyrinth 
to the introduction of pus. If the treatment detailed under the cap- 
tion "Chronic Suppuration of the Middle Ear' does not succeed, after 
persistent effort, in diminishing and finally stopping the foul dis- 
charge, it is safe to infer that there is a carious condition of the bone. 
Caries is especially dangerous when the roof of tin 1 middle ear is its 
seat, for it may terminate in a rupture which will admit the pus into 



CARIOUS PROCESSES IN THE TEMPORAL BONE. 



469 



the cranial cavity. When the pyramid is invaded the hearing is de- 
stroyed and an unfavorable prognosis must be given. 

Erosion of the carotid canal may occur, or of the lateral sinus, 
with fatal haemorrhage. Such a case of destruction of the carotid 
canal came under my observation by the kindness of J. E. Davey 
which necessitated a ligation of the common carotid artery. Ee- 
peated copious haemorrhages occurred from time to time, that could 
only be stopped by packing the meatus. Complete recovery followed 
ligation of the common carotid artery. 

Another method of termination is an extension of the caries to 




Fig. 190. — Post-mortem Section of the Temporal Bone, showing a Perforation 

of the Lateral (Sigmoid) Sinus at 1. (Author's Specimen.) 

Borders of sinus bounded by black lines. 

the cranial cavity and lateral sinus, or it may excite suppurative men- 
ingitis or phlebitis, or end in brain-abscess. A perforation of the 
inner table of the mastoid process may allow the pus to filter into 
the current of blood in the lateral sinus, producing pyaemia. The 
writer has such a typical specimen in his collection (Fig. 190). 

This was the case of a man with mastoiditis for whom I advised 
an immediate operation. The physician in attendance deferred the 
operation until, when it was performed, the patient was suffering 
profoundly from pyaemia. A hopeless prognosis was given. Autopsy 
revealed the perforation of the lateral sinus shown in the foregoing 
figure, through which the purulent contents of the mastoid cells were 



470 



CAKIOUS PROCESSES IN THE TEMPORAL BOXE. 



flowing. Fig. 225 is the same mastoid process as Fig. 190, showing 
where the fistula (No. 2) opened beneath the tip of the process and 
the attachment of the sterno-cleido-mastoid muscle, resulting in an 
abscess of the neck, located underneath this muscle. No. 3 shows 
the opening made by a small trephine directly into the antrum, in 



wSm 



Fig. 191. — The Author's Middle-ear Curette. 



which the probe rests. No. 4 is a tuft of cotton in the external au- 
ditory canal. There is no doubt that this patient's life could have 
been saved had the operation been submitted to when it was first 
advised. 

Treatment includes thorough cleansing and disinfecting of the 
suppurating cavities and removal of granulations or polypi, as de- 



h d i 




Fig. 192.— Horizontal Section of the Ear. (After Politzer.) a, An- 
terior wall of the osseous meatus, b, Its posterior wall, c, Section of the 
membrana tympani, of the handle of the malleus, and of the posterior 
pouch, d, Promontory, e, Ostium tymp. tubse. f, Stapes in connection 
with the inferior extremity of the long process of the incus and of the 
tendon of the stapedius, g, Mastoid process, h, Cochlea, i, Vestibule. 
k, Carotid canal. 

tailed in the foregoing pages. Anodynes must be given for severe 
pain. The denuded, roughened bone, if within reach, should be 
scraped free of all carious tissue with the middle-ear curette (Fig. 
191), but only the most delicate resort to such procedure should be 
had in case the caries is located on the inner tympanic wall, for it is 
thin and easily perforated when carious (Figs. 192 ami 212). After 



CAEIOUS PEOCESSES IN THE TEMPOEAL BONE. 471 

curetting, the treatment as detailed for chronic suppuration is called 
for. 

Sequestra are removed with ease or difficulty according to their 
size, shape, and location. Patients sometimes present pieces of dead 
bone that have become exfoliated and appear in the syringing process. 
The author has removed quite a large sequestrum from a boy 4 years 
old by means of cotton on a holder. During the examination the 
cotton used for drying out the ear was observed to become engaged 
in the angular spiculae of a sequestrum. So it was twisted firmly into 
them and drawn upon, with the result of extracting the quite large 
sequestrum completely (Fig. 189, No. 2, actual size). Other sequestra 
(actual size) from various cases are shown in the same figure. When 
the sequestra are too large and irregular to be extracted through the 
meatus without inflicting unwarrantable injury, they may be crushed 
by sequestrum forceps and removed in fragments. When an extensive 
sequestrum cannot be removed through the natural channel and sup- 
puration cannot be cured, and especially if urgent or dangerous symp- 
toms supervene, it is advisable to open the mastoid process and re- 
move as much of the posterior wall of the meatus as is required to 
extract all the dead bone. The diseased surface should then be 
curetted, dressed, and treated as detailed under "Mastoid Opera- 
tions." 

The general condition of the patient may call for tonics and 
alteratives, which will readily occur to the practitioner. 



CHAPTER XL. 
EXTENSION OF EAR DISEASES TO THE CRANIAL CAVITY. 

Intracranial complications of suppuration of the middle ear 
take place in the following ways: By an extension of the carious 
process in the temporal bone to the cranial cavity, with evacuation 
of pus into the latter; by extension through the vessels and fenestra? 
that penetrate the bone, resulting in purulent meningitis; by the 
formation of an extradural or brain-abscess, and by septic involve- 
ment of the venous sinuses, resulting in phlebitis, thrombosis, em- 
bolism, and septicaemia. 

Meningitis Complicating Otitis. 

Symptomatology. — Severe and continuous headache, localized or 
general, increasing in intensity and accompanied with photophobia, 
generally characterizes the onset of this disease. There are nausea 
or vomiting, sleeplessness, loss of memory, general hyperesthesia, 
dullness of intellect, and in children delirium and convulsions of the 
face (same side) and extremities. In the advanced stage opisthotonos 
may occur. The pupils are firmly contracted at first, afterward di- 
lated and not responsive to bright light, but they are sometimes un- 
equal. The temperature, like many of the other symptoms, is not 
constant, but it varies from 101° to 105° F. The pulse is accelerated 
at first, becoming slower by cerebral compression, and later again 
increasing. The respiration is irregular and jerky in inspiration, 
followed by a pause, and of a lengthened, sighing character in ex- 
piration. Hemiplegia or paralysis of one or more extremities may 
occur, and when the third, fourth, or sixth nerve is involved strabis- 
mus follows. At last the power over the bladder and bowels is lost, 
the respiration is accelerated, the pulse rapid and compressible, and 
finally general paralysis is followed by coma and death. 

Diagnosis. — This is, many times, difficult to determine, especially 
in children. The elimination of any other affection in the course of 
a purulent inflammation of the middle ear. the occurrence of con- 
stant fever, headache, and vomiting constitute the most important 

(472) 









EXTRADURAL ABSCESS. 473 

diagnostic points. Add to these the signs of injection of the retinal 
vessels and optic neuritis, and the diagnosis is rendered quite certain. 

Prognosis. — Without operation, death. 

Treatment. — If cold is agreeable the icecap should be continu- 
ously applied, bromidia given for pain, and the bowels relaxed. If 
a specific infection is suspected, iodide of potassium is indicated. The 
great fatality warrants an early surgical operation, which is described 
below and in Chapter XLII. 



Extradural Abscess. 

This is a localized accumulation of pus hemmed in by adhesions 
of the meninges to the internal table of the skull. It generally re- 
sults from a slow extension of the disease of the tympanic cavity 
through the thin partition of the bone separating the latter from the 
cranial cavity. 

Symptomatology. — There are generally some fever, intense pain 
over the temporal bone, and the symptoms of meningitis; exacerba- 
tions are followed b}^ improvement after a sudden discharge occurs 
from the ear. The abscess may not be located in any part of the 
motor tract; so that no localizing symptoms appear. Frank S. Mil- 
bury details an instance of suppuration of the middle ear and mas- 
toid process eventuating in a subdural abscess with consequent pres- 
sure on the left temporo-sphenoid lobe of the brain. There were 
facial paralysis of the left side, slight paralysis' of the right arm and 
leg, impaired mentality, and amnesic aphasia. (The Laryngoscope, 
December, 1897.) The temperature rarely rises above 102° F. Ten- 
derness over the painful area is usually present. When the cerebellar 
fossa is invaded, giddiness and vomiting may be expected. 

Diagnosis. — This is obscured, as appears from what has been 
said, by the indefiniteness of the symptoms. The points in diagnosis 
are detailed above. 

Prognosis. — This is unfavorable when the abscess ruptures in- 
ternally, but when it breaks externally or is evacuated by an opera- 
tion recovery may take place. 

Treatment. — Operative treatment only is effective. It consists 
of laying bare the tympanic cavity by the Stacke method (see "Mas- 
toid Operations"), evacuating the pus-cavity,, removing all granula- 
tions and dead bone, cleansing, disinfecting, and dressing with aristol 
or iodoform and sterilized gauze. If no pus is found and the cerebral 



474 CEREBRAL AND CEREBELLAR ABSCESSES. 

pulsation is absent, as often happens in brain-abscess, the aspirator- 
needle may be used to explore the site of a suspected pus collection. 

Cerebral and Cerebellar Abscesses. 

These are the result of a chronic, rather than acute, suppuration 
of the middle ear. Over one-fourth of all cerebral abscesses follow 
this disease. Twice as many men as women are subject to brain- 
abscesses. They are generally located either in the temporal lobe or 
in the same side of the cerebellum as the aural disease (Bergmann). 
They may be deep-seated or superficial, single or multiple, in one or 
both sides of the cerebrum. Caries in the roof of the tympanum 
usually causes cerebral abscess, which covers the posterior surface 
of the pyramid, but caries in the mastoid process causes cerebellar 
abscess. The size of the pus-cavity resulting varies from an eighth 
of an inch (three millimetres) to several inches (centimetres) in 
diameter. 

Symptomatology. — Bergmann classifies the symptoms of such 
abscesses as follow: 1. Those of suppuration: paroxysmal fever, 
chills, dullness, mental depression, loss of appetite, indigestion, rise of 
temperature in region of abscess, and tenderness on percussion. 2. 
Pressure symptoms : headache, dizziness, unconsciousness, delirium, 
twitching and paresis in extremities and facial muscles, strabismus, 
disturbance of vision and speech, slow pulse, sleepiness, Cheyne- 
Stokes respiration, eclamptic attacks, and intermissions. 3. Pus in 
the temporal lobe, with inability to speak certain words, is a rare 
condition. When located in the cerebellum it produces dizziness and a 
staggering gait. 

The time-limits of brain-abscess are very variable. It may exist 
indefinitely without urgent symptoms. An old abscess contained 
within a connective-tissue capsule may remain innocuous until it 
ruptures outwardly, producing meningitis, or until encephalitis su- 
pervenes in its vicinity, or it may discharge into the ventricle. A 
fatal issue may result from metastatic abscesses. For example, the 
writer has seen the whole anterior aspect of the thigh converted into 
an immense pus-reservoir. There is a marked predilection for the 
lungs. The end may be preceded by cerebral compression, great 
prostration, or paralysis of the respiratory or circulatory centres. 

Diagnosis. — This is sometimes impossible, for the symptoms are 
absent until the end approaches. When the health steadily declines 



OPERATIONS FOR BRAIN-ABSCESSES. 475 

without other assignable cause, coupled with otorrhcea, insomnia, con- 
stant temperature of about 99° F., localized pain in the same side of 
the head or in the occiput, we are safe, by the process of exclusion, 
in arriving at a diagnosis of this disease. 

Prognosis. — Without operative interference the termination is 
fatal, but the prognosis has been illuminated with the brilliant rec- 
ords of Macewen and Korner, 95 per cent, recovering from operations 
by the former and 60 per cent, of the cases compiled by the latter. 

Treatment. — Until a diagnosis can be made, there remains little 
to do except to direct our efforts toward improving the general health 
and relieving temporary symptoms. A surgical operation is the only 
curative measure. 



Operations for Brain-abscesses. 

Eef erring to the skull (Figs. 209 and 210) that the author has 
prepared to illustrate the various operations for trephining and for 
mastoid diseases, the surgical relations of the parts involved will ap- 
pear. The field of operation is prepared on the previous day by shav- 
ing, scrubbing with soap and water, and afterward with alcohol or 
ether, leaving a generous margin hairless (Fig. 224). Then the head 
is bandaged with sublimated gauze. The bowels are relaxed by a 
saline draught on the previous evening and evacuated by an enema 
on the morning of the operation. Nothing but beef-tea is allowed 
on the operating day. While ether is generally to be preferred in 
other operations, chloroform is allowable in this instance, since it 
causes a depression of the cerebral centres, while ether acts as an 
excitant. 

The point selected for the centre of the half-inch trephine is 
seven-eighths of an inch above the centre of the meatus (Fig. 209). 
Incisions at right angles to each other are usually made, intersecting 
each other at this point, although Horsley prefers a semicircular flap. 
The cut should penetrate to the bone, and all the soft tissues are 
raised (Fig. 204), preserving the periosteum, and retracted by the 
double hooks (Fig. 205). The trephine now having been used, if the 
opening is not capacious enough it can be enlarged without injuring 
the dura by an ingenious device of De Yilbiss, of Toledo, or with the 
chisel. The dura is opened in a valve-shaped flap by a circular in- 
cision one-eighth of an inch inside the bone-perforation, so as to 
permit of this remaining margin being sewed to the flap of the dura 



476 OPERATIONS FOR BRAIN-ABSCESSES. 

afterward if necessary. If there is no cerebral pulsation the abscess 
may be expected to be superficial, but even if pulsation is present 
there may be a deeply seated pus-cavity. 

The aspirating-needle should now be inserted in the supposed 
direction of the abscess if no pus appear. Or a sharp bistoury may 
be cautiously introduced once or twice or even a third time in dif- 
ferent places. If pus escape the opening is enlarged, as complete 
evacuation as possible is effected, and the cavity is cleansed, disin- 
fected, and packed with iodoform gauze, or a rubber drainage-tube 
may be inserted. If no pus is found the dura is sutured; the bone 
button, having been preserved in sterilized warm water, is replaced; 
the periosteum is stitched in situ, the soft parts are brought together, 
and the skin-wound is closed with the finest catgut suture. Sterilized 
gauze, absorbent cotton, and a bandage constitute the dressing em- 
ployed. 

When the abscess is located over the roof of the mastoid antrum, 
the latter is opened, and in most of these cases it is filled with either 
pus or a cholesteatoma. Enough of the roof of the antrum is chiseled 
away to allow of examination of the dura. If the latter is covered 
with granulations or if no pulsation is present, it should be entered. 
If no pus is found, a way is made leading to the roof of the middle 
ear (Krister), avoiding the facial nerve and semicircular canals by 
going above the former and external to the latter. An incision is 
then made in the middle portion of the temporal lobe. The after- 
treatment is described above. Knapp performs the tympano-mastoid 
cranial operation for otitic brain-abscess. 

F. L. Jack reports a case of brain-abscess over the tegmen tym- 
pani, with aphasia, resulting from middle-ear suppuration. Recovery 
took place after an operation with chisel and rongeur forceps through 
the squamous portion of the temporal bone, exposing a large surface 
of the middle cranial fossa. 

Cerebellar abscesses may be reached by chiseling the mastoid 
process so as to penetrate the posterior fossa without opening the 
lateral sinus, or the trephine may be used so as to perforate the occi- 
put between the occipital and the lateral sinuses (Fig. 209, r). It 
should not be forgotten to always give a very guarded prognosis. 
Besides the causes of fatal termination already mentioned the end 
may be hastened by haemorrhage from the middle meningeal artery, 
gangrene of the brain, pyaemia, and prolapsus of the brain. Zaufal 
first opens the posterior fossa, and if results arc negative then the 



SINUS-PHLEBITIS AND SINUS-THKOMBOSIS. 477 

middle fossa, if the cranial cavity is to be opened after a mastoid 
operation. 

Sinus-phlebitis and Sinus-thrombosis. 

These complications result from caries or necrosis of the poste- 
rior tympanic wall in a considerable proportion of cases, but the 
lateral (sigmoid) sinus is the vessel most often affected. The supe- 
rior perosal and cavernous sinuses and the internal jugular vein are 
rarely involved; the latter is in caries of the inferior tympanic wall. 
While the cause is generally an extension of the necrotic process of 
the bone to the walls of the sinus, phlebitis may also result from 
septic infection transmitted by the veins communicating with the 
sinus. We may have accompanying this condition cerebral abscess 
or meningitis. The preceding suppuration has generally, but not 
always, been of long duration. The attack is sudden and character- 
ized by pain in the occipital region and neck, chills, loss of appetite, 
and a temperature above 104° F., with remissions. The pulse is rapid, 
the skin dry, the tongue dry and coated, but consciousness may or 
may not be atfected. Occasional symptoms are dizziness, stiffness of 
the muscles of the neck, optic neuritis, vomiting, delirium, convul- 
sions, coma, and others suggestive of septicaemia. When the internal 
jugular vein is affected, a dense cord, tender on pressure, may be 
distinguished along the anterior border of the sterno-mastoid muscle 
if the neck has not become too cedematous. If the cavernous sinus 
is involved the oedema may extend to the face, nose, and eyelids. 
The fatal termination, which often occurs in about three weeks, is 
most likely to result from pyaemic pneumonia. However, the dura- 
tion varies greatly from a few days to months. Kecovery cannot be 
expected without surgical interference. 

Treatment. — Stimulants, nourishing diet, and antipyretics are 
indicated until the operation is decided upon. The mastoid process 
should be opened (see "Mastoid Operations") and the sigmoid sinus 
laid bare. If it has not the natural dark-blue color or pulsation, but 
is hard, thickened, and inflamed, a thrombus is probably present. If 
a broken-down thrombus or pus is present, there will be fluctuation 
and absence of pulsation. The aspirating-needle should be inserted 
to ascertain the nature of the contents. If either condition mentioned 
is found, the sinus should be laid open longitudinally with a sharp 
bistoury, cleaned out with forceps and curette, washed with bichloride 
solution, 1 to 2000, and dressed with iodoform gauze. 



478 THROMBOSIS OF THE INTERNAL JUGULAR VEIN. 

If the internal jugular vein is thrombosed, it should be ligated 
low enough in the neck to get below the thrombus. The upper seg- 
ment is brought out of the wound, the thrombus removed, and the 
vein is treated as already indicated. This will prevent infection of 
the lungs if resorted to early enough. 






CHAPTER XLL 

DISEASES OF THE MASTOID PROCESS. 

Pathology. — Primary acute inflammation of the mastoid process 
is a rare disease. Any affection of this part is nearly always conse- 
quent npon a middle-ear inflammation. The disease may be limited 
either to the lining membrane of the pneumatic spaces or to the peri- 
osteum of the cortex, or both membranes and the bone itself may be 
involved. In the acute form the latter condition is most likely to 
prevail, especially when it is consecutive to an acute middle-ear sup- 
puration. Unless the inflammatory process is speedily interrupted, 
necrosis of the bone ma}^ occur, with a growth of unhealthy granula- 
tions; the formation of a fistula, either externally through the cortex, 
presenting a post-aural abscess, or through the posterior wall of the 
bony meatus (Fig. 210), or internally, communicating with the cranial 
cavity through the lateral-sinus wall (Fig. 190) or through the roof of 
the tympanic cavity. In this manner the posterior or the middle 
fossa (Fig. 193) may be invaded by the purulent discharge, thus giving 
rise to meningitis, subdural abscess, sinus-thrombosis, pyaemia, or 
brain-abscess. M. D. Lederman reported a case of extension of mid- 
dle-ear and mastoid suppuration to the cranial cavity, in which "sof- 
tening of the lower portion of the right temporo-sphenoid lobe of the 
brain was found, accounting for paralysis of the arm and leg of the 
opposite side" (The Laryngoscope, July, 1896). Moos (Archives of 
Otology, July, 1894) reported a case of "mastoid disease extending 
outward by Avay of the mastoid fissure, the continuation of the petro- 
squamous suture." 

In the more favorable cases the discharge contained within the 
antrum and cells may find exit through the middle ear and external 
canal, or, if pus form beneath the mastoid periosteum, the resulting 
post-aural abscess may rupture spontaneously. This often occurs 
when the pus has found its way from the antrum through a fistulous 
opening in the cortex; so that the mastoid antrum comes into direct 
communication with the external world. In 1884 the author treated 
such a case in a lady nearly 80 years old. The discharge had ceased 

(479) 



480 



DISEASES OF THE MASTOID PROCESS. 



and there- -was a fistulous opening, surrounded by the blackened, ex- 
posed bone three-eighths of an inch (one centimetre) in diameter, 
leading into the tympanic cavity. The hearing for conversation was 
not lost, no inconvenience was suffered, and she did not wish the 




Fig. 193. — Interior of Base of Skull. (Author's Preparation.) LS, 
Lateral (sigmoid) sinus. 11, Parallel lines over the superior semicircular 
canal. 0, internal auditory meatus. X, Opening by trephine for abscess 
over the middle ear. The cranial fossnn and sinuses are shown. The 
lateral sinus of the right side extends farther forward than the left. 



opening to be closed. The patient remained in excellent health when 
last seen, twelve years afterward. 

An occasional result of inflammation of the mastoid cells is a 
proliferation of osseous tissue, which fills and obliterates the pneu- 



DISEASES OF THE MASTOID PROCESS. 481 

matic spaces, leaving the whole area a dense, ivory-like mass. I have 
enconntered a few such processes in which no pneumatic cells could 
be found, and the chisels were bent and chipped as though driven 
against stone (osteosclerosis). 

Etiology. — Primary mastoiditis may occur as the result of trau- 
matism or exposure to cold. Generally mastoid disease is a complica- 
tion and is most prevalent during influenza epidemics. In the latter 
case, at least, it is probable that a bacterial infection occurs through 
the Eustachian tube from the respiratory passages, since it has been 
demonstrated that the diplococcus of pneumonia is present in the 
mastoid discharge (Scheibe). Frank Eumbold reported a case of 
mastoiditis in April, 1898, in which he attributed the attack, in a 
patient suffering from diabetes, to carious teeth of the lower jaw. 
After a mastoid operation had been performed without marked relief 
the diseased teeth were extracted, after which the patient experienced 
freedom from pain and made a good recovery. 

It should be borne in mind that the relations of the antrum and 
middle ear, being connected by the aditus ad antrum, or passage from 
the tympanic attic to the antrum, are such that any fluid in the tym- 
panic cavity naturally gravitates into the mastoid antrum when the 
patient reclines upon his back. Indeed, the antrum is the drip-cup 
of the tympanum, and whenever there is considerable fluid in the 
middle ear it finds its way into the antrum. This does not of neces- 
sity imply an inflammation of the pneumatic cells, but when micro- 
organisms — streptococci, etc. — are present the danger to the integrity 
of the lining membrane and delicate cellular structures is apparent. 
i Symptomatology. — Acute mastoiditis is accompanied with pain, 
which, though only slight and annoying at first, becomes violent and 
exhausting as the disease progresses. After a few days the tongue be- 
comes coated and the temperature elevated two or three degrees. If 
there is periostitis there are also tenderness, redness, and swelling over 
the mastoid region. Pain is sometimes referred to the temporal, the 
supra-orbital, or the occipital region. Pluctuation denotes either a 
subperiosteal abscess or a fistula. Great variations in temperature 
during the day should excite suspicion of sinus-thrombosis; but as 
descriptions of intracranial complications have already been given 
(Chapter XL) they will not be repeated here. A most noticeable sign 
of mastoid periostitis and oedema of the overlying structures is a pro- 
nounced prominence of the auricle, which projects out conspicuously 
at a right angle to the side of the head. 

31 



482 DISEASES OF THE MASTOID PEOCESS. 

Pain is not always present in mastoid disease, especially after 
the acute stage has passed, and one must not expect to find the whole 
group of symptoms present in every case. They are not constant. 
Great destruction may take place in the process without proportionate 
discernible manifestations. This demonstrates the insidious and dan- 
gerous character of the disease. If there is no ear discharge in acute 
mastoiditis of the cells, one may expect to find a bulging drumhead, 
and the postero-superior wall of the meatus may be found depressed. 

The inflammatory process may continue for several weeks with 
recurrences and remissions of the symptoms, but the closest watch 
must be kept in order that any impending invasion of the cranial 
cavity may be averted by prompt surgical interference. Pus may in- 
vade the middle fossa through the tympanic roof or antrum. If it 
break posteriorly from the middle ear or mastoid cells, it reaches 
either the lateral sinus or the posterior fossa. If it advance ante- 
riorly from the middle ear, it may form a superficial abscess in the 
neck or a retropharyngeal abscess. It may break through the inferior 
surface of the mastoid process and form an abscess beneath the sterno- 
mastoid muscle (Fig. 225). If it find an outlet through the inferior 
surface of the petrous portion of the temporal bone, it may burrow 
beneath the deeper layer of muscles even to the thoracic cavity. 
When the cervical tissues become infiltrated in the region of the 
sterno-mastoid muscle, or an abscess of the neck forms, the head be- 
comes more or less fixed, the face everted, and movements involving 
this muscle are restricted and painful. When a retropharyngeal ab- 
scess is present the jaw is fixed and cannot be moved or depressed 
sufficiently to examine the tongue or throat except with great pain 
(Plates III and IV). 

Diagnosis. — In acute mastoiditis the symptoms enumerated are 
so prominent and characteristic that no difficulty presents itself in 
recognizing the condition, but in chronic suppuration of the mastoid 
cells, in the absence of a fistula, it is not so simple a task. Persistent 
discharge, notwithstanding the treatment, foul odor, bulging of the 
postero-superior wali of the canal, tenderness over this region, and 
impaired nutrition indicate a mastoid disease. 

Prognosis. — Uncomplicated acute mastoiditis, subject to early 
treatment, presents a favorable outlook. A large proportion of such 
cases will recover without an operation; but the treatment must be 
instituted promptly in order to prevent extensive destruction of the 
bone, and intracranial complication. When the latter occurs the 



DISEASES OF THE MASTOID PROCESS. 483 

prognosis is unfavorable without an operation; but surgical interfer- 
ence presents good chances of recovery if not delayed until the occur- 
rence of septicaemia, brain-abscess, sinus-thrombosis and phlebitis, or 
meningitis. Yulpius (Archives of Otology, April, 1895) reports three 
cases of influenzal otitis, mastoiditis, and epidural suppuration cured 
by operations. 

Treatment. — If the patient is seen before perforation of the 
drumhead occurs, and signs of fluid in the middle ear are discovered, 
paracentesis should be performed at once, as described in treating of 
acute inflammation of the middle ear (page 402). The incision should 
be a long one, for its tendency is to close soon. A case to the point 
occurred while writing this. It became necessary to make an ex- 
tensive opening in the drumhead and to incise the bulging posterior 




Fig. 194.— The Author's Icebag. 

wall of the meatus, under ether, although a few days earlier a minute 
perforation was enlarged under cocaine. The first incision had healed, 
the discharge ceased, and great pain and a sense of pressure ensued 
from the accumulated pus that was unable to escape. 

In acute inflammation the icebag (Fig. 194) should be applied 
without delay, and kept continuously in place until either the in- 
flammation subsides or it becomes evident that an operation is im- 
perative. The crushed ice must be replenished as fast as it melts. 
One or two days may be long enough, but I have found it necessary 
at times to maintain constant cold for three or four consecutive days 
and nights. Sometimes an exacerbation occurs and the ice must be 
resorted to again. This plan succeeds in some very serious cases, but 
if pus has formed the ice may fail. For example: two children about 



484 DISEASES OF THE MASTOID PEOCESS. 

6 years old presented acute mastoiditis on the same day, and ice was 
applied alike to both. In five days one was discharged cured and the 
other developed a post-aural abscess, on opening which a fistula was 
found leading to the antrum. The icebag was powerless in the one 
case to avert a mastoid operation, because destruction of osseous tis- 
sue had already taken place. 

Counter-irritation by mustard over the whole mastoid region, 
and along the course of the Eustachian tube when it is involved, 
often assists materially. It should be used nearly, but not quite, 
to the point of vesication, and then replaced by spirit of camphor on 
a flannel compress until the blush fades and the cutaneous irritation 
is again indicated. 

Leeches afford speedy relief during the acute, intense stage of 
the inflammation. They should be applied over the mastoid process 
near the auricle. Detailed directions for applying leeches will be 
found in the treatment of acute inflammation of the middle ear 
(page 405). General antiphlogistic treatment and anodynes are fre- 
quently called for, with laxatives for the bowels, as mentioned under 
the same heading. 

If the application of the icebag is followed in a few days by 
subsidence of pain, fever, and the other symptoms, or if the cold is 
badly borne, it should be discontinued. If, in spite of all these 
antiphlogistic measures, the steady march of the destructive process 
is not stayed, an operation must not be too long delayed. A week 
or ten days may give sufficient time for extensive infiltration and 
invasion of the more vital organs. Nevertheless, the writer has seen 
numerous instances in which very grave and alarming symptoms have 
yielded to this palliative method of treatment, — cases in which ex- 
cellent surgeons believed an operation to be unavoidable. 

But it is a matter of duty to emphasize the possibility of a sud- 
den fatal termination if the necessary operation is too long post- 
poned. Fatal results have followed such delays and refusals to allow 
operations, but I have never seen a fatal termination due to the 
operation itself. The disease is dangerous; the operation itself, in 
the hands of a competent operator, is not. If the mastoid process con- 
tain necrotic tissue, the operation affords immediate relief. It gives 
free exit to the pent-up discharges and removes a threatening cause 
of disaster. 

"I have memoranda of 143 cases operated upon for mastoid dis- 
ease. Of these, 127 uncomplicated by pyogenic brain disease recov- 



DISEASES OF THE MASTOID PROCESS. 485 

ered. A few have required a second and even a third operation. In a 
few the recovery has been slow and tedious; but in no case has death 
resulted, directly or indirectly, from the operation, and in no case, so 
far as I have been able to learn, has death resulted from a return of 
the disease." (A. E. Baker.) 

Edwin W. Pyle has reported his experiences in 100 mastoid op- 
erations, in which he had a mortality of 4 per cent. He says : "Four 
cases were operated upon, perhaps, too early and ill advisedly, but 
beyond the possibility of a doubt 96 would have been vastly benefited by 
earlier operative procedure." (Archives of Otology, volume xxx, No. 
3, 1901.) 

Any well-informed surgeon, after sufficient practice on the ca- 
daver, can perform the operation with safety and success if he follow 
closely the rules laid down; but, in order to have well at command 
all the surgical relations of the parts concerned, the operation ought 
to be previously studied and performed numerous times on the ca- 
daver. To illustrate : out of 17 mastoid operations which the author 



Fig. 195. — Buck's Mastoid Knife. 

has made in one month, 12 were upon cadavers and 5 only upon 
patients. 

M. D. Lederman advises, as an abortive measure, incision through 
the posterior fold of the drumhead, extending through Shrapnell's 
membrane and into the superior wall of the meatus, so as to produce 
free blood-letting. (The Laryngoscope, January, 1898.) 

Wilde's incision, at least, should be made as soon as it becomes 
evident, by the presence of a fluctuating swelling back of the ear, 
that pus is present. Anyone can do this with a sharp, strong bis- 
toury (Fig. 195). The cut is made as nearly as possible in the line 
of the incision that may be required later for the mastoid operation, 
— about three-eighths of an inch (one centimetre), posterior to the 
insertion of the auricle and parallel with it (Fig. 216). The incision 
is carried down to the bone, the pus evacuated, and a fistula searched 
for with a strong probe. If none is present, and it is apparent that 
the abscess is subperiosteal, and no superficial caries of the bone 
needs curetting, the cavity is treated antiseptically, as will appear 
later, until pus formation ceases. Then it is allowed to close. 



486 



INDICATIONS FOE MASTOID OPERATIONS. 



Indications and Preparations for Mastoid Operations. 

Indications for Operating. — The following six rules, by which 
the perplexing question of when to operate is decided, were presented 
by the writer in a paper before the first Pan-American Medical Con- 
gress, and received, with unanimity of opinion, the approval of the 
aural surgeons present, including Professor Politzer: — 




Fig. 196. — The Nevius Electric Head-lamp. 

The mastoid process should be opened 

1. When there is acute inflammation of the bone that resists 
palliative treatment. 

2. When repeated swellings and abscesses occur. 

3. When there is a bulging of the posterior and superior wall 
of the meatus, with suppuration of the middle ear. 

4. When there is a fistula. 



Fig. 197. — A Strong Scalpel. 



5. When there are severe pains in the same side of the head as 
the diseased ear and they resist all other treatment. 

6. When a foul otorrhcea cannot be cured by any other means. 
These rules may be termed conservative, and whatever deviation 

we may indulge in ought to be at once favorable to the operation 
and the welfare of the patient. Too great temporizing favors sinus- 
thrombosis, septicaemia, brain-abscess, and meningitis. 



PREPARATIONS FOR MASTOID OPERATIONS. 



487 



There are a few points in this connection worth mentioning, for 
they are closely related to a successful issue. Excellent illumination 
is had by the use of light reflected from a mirror on the operator's 
forehead, after the cortex is opened (Fig. 110). This affords a decided 
advantage over window-light. It is more intense, especially from the 
60-candle-power incandescent gas-burner (Fig. Ill); it can be 
thrown into the opening of the bone in every direction, and there are 




Mr-^^JiMli M 



Fig. 198.— The Author's Mastoid Chisel. Actual Width. 

no shadows to obscure the field. The Nevius electric head-light (Fig. 
196) affords an ideal illumination for mastoid operations. It is at- 
tached to the head-band by a ball-and-socket joint, and it gives a 
very brilliant light, exceeding a 16-candle-power lamp. It is op- 
erated by connecting it by a plug to an incandescent-electric-lamp 
fixture. We have used this illuminator in mastoid operations with the 
utmost satisfaction. 




KA«CtWW^^ WNW1,U< l^lM 




^3 



M^l^W* Na *^* W ^iiriStiSniIi* 3 * wc ' w ^ t 



^««WCBM«OTMSXHIW»P 



Fig. 199. — The Author's Long Mastoid Gouges. Actual Width. 

Preparation of the Patient. — The day preceding the operation 
the patient's mastoid region, together with an area three inches 
in extent above and behind the auricle, is shaved and washed with 
soap and warm water, then with ether, and finally with very warm 
bichloride solution (hydrargyrum bichloride), 1 to 1000. The meatus 
is syringed with the latter solution. The parts are then dressed with 
sublimated gauze and a bandage. The bowels are relaxed the same 



488 



PREPARATIONS FOR MASTOID OPERATION'S. 



evening, and beef-tea only is allowed on the day of the operation. 
Ether is preferable to chloroform on account of its greater safety. 
Only so much as is absolutely necessary to procure freedom from pain, 
movement, and shock is employed, in order to avoid a subsequent 
bronchitis or pneumonia. 

The patient's clothing is removed from his shoulders and a 
blanket, covered with a rubber sheet, is substituted, so as to have 
the clothes clean when he is returned to bed. The hair, especially in 




Fig. 200.— Lead-filled Mallet. 



the case of females, need not be entirely sacrificed (Fig. 224), as is 
often done, but it is preserved in a cleanly condition by enveloping it 
in a sublimated cap or towel or a rubber cap. 

The operator and assistants prepare by rolling the sleeves above 
the elbows and vigorously scrubbing their forearms, hands, and nails 
with brush, and warm water and soap, and last with alcohol. Eubber 
aprons and operating-gowns complete the surgeon's toilet. A table 






Fiff. 201.— The Author's Set of Curettes. 



forty-two inches high is preferred by the writer in order to escape 
the necessity of a wearying, stooping position during the operation. 
The patient's head rests on a small rubber drainage-cushion (Fig. 
206). 

The instruments, a quarter of an hour before they are needed, 
are boiled for five minutes in a 1-per-cent. solution of bicarbonate 
of sodium, which does not corrode, and then they are placed in warm, 
sterilized water. The scalpels are simply immersed in boiling water 



INSTRUMENTS FOR MASTOID OPERATIONS. 



489 



n moment. For many years the writer used a 5-per-cent. carbolic- 
acid solution for the instruments, instead of boiling, but a serious 
objection to this was that the operator's fingers were benumbed by 
the acid, for the instruments were kept immersed in the solution 
■during the operation. 

The instruments required are a couple of strong, sharp scalpels 
(Fig. 197), four artery-forceps, a periosteum elevator, self -retaining 
retractors, a strong chisel (Fig. 198), three sizes of long gouges (Fig. 




Fig. 202.— The Author's Mastoid Guide. 



199), a metal mallet (Fig. 200), several sizes of curettes (Fig. 201), 
strong probes and forceps, a mastoid guide (Fig. 202), tongue-forceps 
(Fig. 203), and a syringe (Fig. 143), with hot water. 

The periosteum elevator, retractor, and curette is a hoe-shaped 
device (Fig. 204) which overcomes a serious objection to the mis- 
named periosteotomes we have formerly used. Indeed, these instru- 
ments should not be "tomes" at all. They should not cut the mem- 




Fig. 203. — Mathieu's Tongue-holding Forceps. 



brane, but should lift it from the bone in continuity, so as to carefully 
preserve its integrity. 

The old periosteotomes put the operator at a disadvantage by 
necessitating an unnatural play of his muscles. With a pushing mo- 
tion one has not perfect control of the movements of the instrument 
and it is likely to slip and cut where it is not desirable to wound. In 
the use of this kind of a lifter the motion is one of drawing or pulling 
toward one's self; so that the muscles brought into play are, together 



490 



INSTRUMENTS FOR MASTOID OPERATIONS. 



with the instrument, under easy control, — on the same principle as- 
the farmer's use of his hoe, after which it is patterned. 

As the separator serves the purpose not only of detaching the 
periosteum, but of retracting the loosened tissues, or of curetting 
necrosed bone, it may be said to constitute three instruments in one. 

The self-retaining retractors (Fig. 205) take the place of an as- 
sistant in keeping the soft tissues out of the way of the operator and 
in controlling the haemorrhage during mastoid and other operations 




The Author's Periosteum Elevator. 



of like magnitude. The retractors consist of two shafts, each armed 
with a series of hooks that can be brought together and' interlocked 
for insertion into the incision, when they can be separated and fixed 
at any desirable point up to two inches apart. After they have been 
drawn apart as far as may be required, the thumb-screw on the fixa- 
tion-bar next to the hooks should be screwed down firmly into the 
bar, the handles should be pressed a little together until the tissues 
are well stretched as the distal ends of the retractors separate, then 










Fig. 205. — The Author's Self-retaining Retractors. 

the thumb-nut on the thread-bar should be turned down against the 
movable handle. 

If the instrument is properly adjusted the tissues cannot slip out 
of its jaws, and their pressure on the stretched lips of the wound 
reduces the haemorrhage to a minimum. In some operations these 
hooks have proved more effective than five artery-forceps. 

The following arrangement renders these retractors equally use- 
ful in the smallest and the largest mastoid operations: The terminal 



CHOICE OF OPERATIONS. 491 

half of the shaft of hooks can be slipped out of the main half, leaving 
the retractors only an inch long. Replacing the adjustable series of 
hooks makes them two inches long, and by drawing these adjustable 
hooks outward one-half inch one can lengthen the hooks to two and 
one-half inches. This has the effect, when the instrument is in 
position in a large wound, of making an opening two inches to three 
and one-half inches wide by three or more inches long, through which 
to work. However, the opening can be made as small as one wishes, 
and the capacity of the instrument is far beyond what we usually re- 
quire in operations on the skull; but the writer has had it made so 
as to be of service in other and more extensive operations, since its 
size in no way impairs its efficiency in mastoid cases. The handles 
are constructed to take up as little room as possible. 

When the adjustable parts of the hooks are removed for small 
operations the openings in the permanent hook-shafts, into which 
the adjustable hooks fit, may be securely sealed by a bit of beeswax 
to prevent the entrance of blood, etc. After being used, this wax 
will run out on the application of a little heat. A drop of oil should 
then be put in the same openings to prevent corrosion or sticking of 
the adjustable shanks. 

The straight-edged chisel is employed to open the firm cortex, 
but after the antrum or cells are reached the writer's long gouges are 
better adapted to the work (Fig. 199). The length of the shafts al- 
lows the operator's hand to be sufficiently removed from the cavity to 
give an unobstructed field of vision. 

As we cannot know the extent of the pathological process before 
entering the bone, it does not appear to be advisable to decide in ad- 
vance upon any special method of procedure save one : remove all 
dead and diseased tissue. Whatever method does this is best. 
Stacke's and Bergmann's operations have the advantage of affording 
the greatest accessibility to the tympanum; so that if it is necessary 
to remove necrosed ossicles or diseased tympanic tissue it can be done 
with greater facility and thoroughness. 



CHAPTER XLIL 

THE MASTOID OPERATIONS. 

For our purpose it is most convenient and practical to treat of 
mastoid operations under three headings: (1) the Schwartze mastoid 
operation; (2) the radical tympano-mastoid operation; (3) the modi- 
fied operation. 

The Schwartze operation is the one most commonly performed, 
and is adapted for primary mastoid abscess, or that condition in which 
it is necessary to penetrate the bone without entering the tympanic 
cavity. 

The radical operation, devised by Stacke, is much more exten- 
sive and complicated, and is intended to open not only the antrum, 
but to expose the whole tympanic cavity and to remove one or more 
of the ossicles and any diseased tissue that may be found in the mid- 
dle ear. 

The modified operation is a convenient combination of the best 
principles governing the other two, more thorough than the first, and 
less menacing to important structures than the second. 

The Schwartze Mastoid Operation. 

All preparations having been made as already detailed (Figs. 206 
and 207), the ear cleansed, etc., the auricle is bent forward and the 
incision is made, beginning at the apex of the mastoid and extending 
upward and forward until within three-eighths of an inch (one centi- 
metre) of the auricular attachment; then it is carried parallel with the 
auricle to a level with its superior attachment. The incision should be 
made from below upward, for if made in a downward direction it is 
possible for the knife to slip off from the rounding surface of the mas- 
toid tip and plunge into the soft tissues of the neck, for one naturally 
bears hard upon the knife to cut to the bone. The posterior auricular 
artery or its anterior branch will have been severed and is caught up 
with the small artery-forceps and twisted. The forceps can be left 
holding it, instead of stopping to ligate. 
(492) 



THE SCHWARTZE MASTOID OPERATION. 



493 



The bleeding may be considerable for a few minutes, and if a 
pus-cavity is opened the contents usually gush out with considerable 
force. The haemorrhage is dried rapidly with small pieces of moist 
sterilized gauze, the assistant consuming as little time as possible. 
If necessary, several small artery-forceps can be used to arrest the 
venous flow, and they can be left in situ when the retractors are 




Fig. 206. — A Mastoid Operation. 



applied. The periosteal elevator (Fig. 204) is now used to separate 
the periosteum backward far enough to expose all the surface cov- 
ering the cellular part of the bone, and forward to the posterior mar- 
gin of the external meatus. The periosteum should be kept intact 
and carefully preserved. The self-retaining retractors (Fig. 205) are 
then inserted into the wound, the teeth being interlocked and resting 



494 



THE SCHWARTZE MASTOID OPERATIOX 



on the denuded bone. They are then separated as far as possible 
and fastened as previously described. In short incisions, as in chil- 
dren, the additional hooks are not needed. The haemorrhage now 
practically ceases from the soft tissues because of the pressure and 
stretching by the hooks. If a fistula in the bone is found, it is en- 
larged; if there is none, and the antrum is sought, the bone is opened 
on a level with the superior border of the external meatus and three- 
eighths of an inch (one centimetre) back of its posterior wall (Figs. 
208, 209, and 210). 

The mallet and straight-edged chisels are used to remove the 
cortex in preference to the trephine or drill. The broad chisel is best 





Fig. 207. — Operating-room and Accessories. 



here. The strokes of the mallet must always be light enough to run 
no risk of forcing the chisel through softened bone into the vital 
parts. The cortex over the antrum varies greatly in thickness. In 
large pneumatic processes it may be as thin as an eggshell, and it can 
be easily penetrated with a strong probe, while one may drill a half- 
inch into a typical sclerotic process without rinding a pneumatic 
cavity. 

The general direction of the cone-shaped mass of bone to be re- 
moved is inward, forward, and a little upward (Fig. 208); but one 
must always bear in mind thai these are relative terms, for we speak 
as if the patient were in an upright, instead of a supine position. A 



THE SCHWAETZE MASTOID OPEEATIOX. 



495 



good rule is to keep close to the meatus, follow its direction, and keep 
above the horizontal plane of its axis if the antrum is to be opened 
(Fig. 211) and the facial nerve avoided. 

As soon as the cortex is removed the forehead-mirror or electric 
lamp (Figs. 110 and 196) and brilliant illumination should be used 
(Fig. 111). If dead bone is reached there is little or no difficulty in 




Fig. 208. — Horizontal Section through Right Temporal Bone, cut Two 
Millimetres above the Center of the External Canal. (After C. R. 
Holmes.) 0, Opening in mastoid leading to antrum; the heavily dotted 
lines indicate the depth to which the opening penetrated in the upper sec- 
tion of this bone; small arrow indicates the relative position of the spina. 

22, Wedge between opening in mastoid and external meatus. M, Mastoid. 

23, Dotted lines indicating how osteosclerosis may increase the depth to 
which it is necessary to penetrate. C, external canal. *, Large cell in 
direct communication with the floor of the antrum above. L8, Lateral 
sinus, z, Posterior semicircular canal. N, Facial nerve, x, Horizontal 
semicircular canal. 2, Vestibule. 1, Internal canal. 3, Cochlea. 4, 
Fenestra ovalis. 10, Eustachian canal. MT, Membrana tympani. 



distinguishing it from the healthy. It is softer, darker, crumbling, 
and is often filled with dark, fungus-like granulations as well as pus. 
It breaks down readily under the curette and should be entirely re- 
moved until nothing but healthy tissue is to be seen. 

The opening in the cortex should be made spacious enough to 
allow of easy inspection of all the interior of the process. In the 



496 



THE SCHWARTZE MASTOID OPERATION. 



adult the oval aperture should be about one-half by three-fourths of 
an inch in diameter or ten by twelve or fifteen millimetres, with the 
long axis in the vertical. The surgeon should be satisfied with noth- 
ing but thoroughness of detail. If the carious bone extend to the 
dura or lateral (sigmoid) sinus it is removed thus far, exercising great 
caution not to injure either, and, although it has often been neces- 
sary to expose both, -we have never seen any ill results follow. If 




Fig. 209. — Side-view of a Skull, showing (Hi) Opening in Mastoid 
Process for Schwartze Operation. (Author's Preparation.) The waver- 
ing black line just above i is the course of the facial nerve exposed; above 
and at the left of this is seen the tympanic cavity, ii, Opening by tre- 
phine to explore the roof of the middle ear. Hi lie over the course of the 
lateral sinus, iv, Eeed's base-line, v, Trephined opening for cerebellar 
abscess. 



the sinus should be accidentally opened, the haemorrhage will be- 
profuse and will probably necessitate tamponing the cavity with iodo- 
form gauze and postponing further operative procedure for a fort- 
night, unless sufficient pressure can be exerted to suppress the bleed- 
ing. 

The variation in the distances between the external canal and 
the lateral (sigmoid) sinus is shown in the same individual on the 
opposite sides of a skull in my possession (Figs. 193, 212, and 213).. 



THE SCHWARTZE MASTOID OPERATION" 



497 



The surgical relations and close proximity of the sigmoid sinus, the 
facial nerve, and the semicircular canals are plainly visible in Figs. 
208, 212, and 214 (LS, N, etc.). 

In Fig. 193 the right lateral sinus extends farther forward than 
the left, as is the rule. "In an examination of 17 temporal bones 
Emil Arnberg found that the thickness of the sinus wall varied from 




Fig. 210. — Schwartze Operation. (Author's Preparation.) View of 
skull from below., showing tympanic cavity, looking from below upward 
and inward. The anteroinferior wall of the osseous meatus is removed. 
i, Postero-superior wall of the meatus; at the right of i is an opening 
into the mastoid cells, ii, Opening above meatus for cerebral abscess. 
ill, Schwartze opening into antrum, v, Opening for cerebellar abscess. 6, 
Exit of facial nerve (black line running downward). 7, Stirrup in fora- 
men ovale. The dark space just above the stirrup shows the opened 
Fallopian canal. 



two and one-half millimetres to ten millimetres, the average being 
five and three-fourths millimetres." A. H. Andrews locates the lat- 
eral sinus by means of a tuning-fork, vibrating in contact with the 
skull behind the mastoid process, and a stethoscope placed over the 
process. The fork is moved forward toward the stethoscope, and "as 
soon as the border of the mastoid is reached a decided increase in the 



498 



THE SCHWARTZE MASTOID OPERATION. 



volume of sound from the fork is noted/' ("Year-book of the Nose, 
Throat, and Ear," 1901.) 

In many cases this operation suffices to effect a cure and it is 
not necessary to proceed farther. All projecting spiculae of bone are 







]0 3\0faM', 



Fig. 211.— Opening of the Antrum. (After C. R. Holmes.) W-W 
and Y-Y, Horizontal and perpendicular planes of the skull. 0, Opening in 
mastoid leading to antrum. OA, Antrum. LS, Lateral sinus. .1/. Mas- 
toid process. 22, Posterior wall of external meatus. 15, Styloid process. 
MT, Membrana tympani. 14, Glenoid cavity. 28, Glaserian fissure. 17, 
Zygomatic process. 12 and 13, Outlines of hammer and anvil and loca- 
tion of attic. 16, Spina supra meatus. *, Dotted lines showing position 
of antrum. E, Linea temporalis. 



THE SCHWARTZE MASTOID OPERATION". 



499 




cxrcrlTT t,t »„ 



JjO /n.rw 



Fig. 212. — Horizontal Section through Right Temporal Bone, showing 
Distance between Lateral Sinus and External Canal. (After C. R. 
Holmes.) Cut begins below center of external canal, passing obliquely 
upward and inward. LS, Lateral sinus. M, Mastoid. N, Facial nerve. 
TC, Tympanic cavity. 2. Vestibule. MT, Membrana tympani. C, Ex- 
ternal canal. Small arrow indicates the point where a perpendicular line 
from the spina supra meatus would touch. 




Fig. 213. — Horizontal Section through Right Temporal Bone, Cut 
Near Center of External Meatus, showing how Close the Lateral Sinus 
may come to the External Canal in Some Cases. (After C. R. Holmes.) 
a, Internal carotid artery. V, Internal jugular vein. For explanation of 
other letters see Fig. 208. 



500 



THE SCHWAKTZE MASTOID OPERATION". 



removed, rough corners rounded off, the wound is syringed with 
quite warm bichloride solution, 1 to 1000, then dried and sprinkled 
with aristol (Fig. 144) or iodoform powder (Fig. 178). The upper sec- 
tion of the wound is stitched to a level with the upper border of 
the bone-opening only. The cavity is packed very lightly with iodo- 
form gauze, covered thickly with absorbent cotton, and the dressing 





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Fig. 214. — Perpendicular Section through the Right Temporal Bone, 
beginning at Line 5-5, behind Opening O in Mastoid (Fig. 211), and Di- 
rected Inward and Forward, cutting Eustachian Tube in its Long Axis. 
(After C. R. Holmes.) N, Dotted lines show the course of the facial and 
chorda-tympani nerves. M, Mastoid. Cli, Chorda-tympani nerve. J/7 1 , 
Membrana tympani. a, Canal for internal carotid. 10, Eustachian tube. 
9, Processus cochliariformis. At, Attic. 7, 8, Showing defects in the 
bone covering attic and antrum. OA, Opening into antrum. (Fig. 211). 
LS, Lateral sinus. *, Antrum. O, Dotted lines indicating funnel-shaped 
opening (Fig. 211). 



is completed with a net or crinoline bandage. These bandages are 
not to be applied very firmly, since the sizing they contain, being 
moistened before they are applied, dries and contracts, setting some- 
what like a plaster-of-Paris bandage. Later, a rubber adhesive plaster 
can be substituted for the bandage (Fig. 215). The wound is kept 
sufficiently open to permit inspection and treatment until the cavity 
fills with healthy cicatricial tissue. 



TIIE SCHYTARTZE MASTOID OPERATION. 



501 




Fig 215. — Adhesive Plaster Dressing for Mastoid Wound. (Author's Case.) 




Fig. 216. — Line of Incision Healed Two Months after a Sclnvartze Operation. 

(Author's Case.) 



502 



THE SCHWARTZE MASTOID OPERATION. 



The patient is now put to bed. In case the temperature was 
high before the operation it usually falls, but it may remain near 
100° F. for a few days. The dressing is not disturbed for four or five 
days unless considerable haemorrhage, discharge, odor, pain, or fever 
should call for it. Too frequent dressings and forcible irrigations 
retard new tissue formation, while too infrequent dressings favor 




Fig. 217. — The Radical Tympanomastoid (Stackc) Operation, Com- 
pleted. Photographed Life Size. 1, Tympanic cavity. 2, Interior of 
mastoid process. 3, Auricle reflected forward. 4, Self-retaining double 
retractors. 



decomposition, septic infection, and exuberant granulations. Even 
in this operation the author often connects the tympanum freely with 
the mastoid opening so as to permit a current of water to pass into 
one and out of the other for the sake of absolute cleanliness. 

The duration of this operation, from the first incision to the 
completion of the operation and insufflation of the powder, has varied 



THE STACKE MASTOID OPERATION. 



503 




Fig. 218. — Side of Skull, showing Stacke Operation. (Author's Prep- 
aration.) The postero-superior wall of the meatus is removed. The an- 
trum is seen below 8 and the oval window at the right of 9. Below the 
oval foramen is seen the round window, and the dark spot above and to 
the right of 9 is an opening into the external semicircular canal. The 
projecting ridge between this and the oval window is the Fallopian, or 
facial, canal. 12, Point for trephining to open the lateral sinus. 



501 



THE RADICAL TYMPAXO-MASTOID OPERATION" 



in my practice from fifteen to thirty-five minutes. With good as- 
sistants one can acquire dexterity in operating without incurring any 
risks, and the patients make a better recovery than when narcosis is 
protracted. The length of time required for complete recovery varies 
greatly. We have had patients leave the hospital in a few days or a 
week and have found them cured at the expiration of the fourth 
week, while others, for various reasons, extend over three or four 




Fig. 219. — Vertical Section through the Ear. (Author's Prepara- 
tion.) 4, Wedge-shaped portion of bone forming outer boundary of the 
tympanic attic; dotted line shows the section removed in the Stacke 
operation. 5, Dotted line shows course of facial nerve: the bright spot 
in the dark area between 4 and 5 is the end of the probe; seen through the 
aditus ad antrum, resting in the antrum. (5. Remnant of the drumhead. 

months. Six or eight weeks would be a- fair average time to give 
as necessary for a cure, and patients should be informed thai it may 
require longer (Fig. 216). 



The Radical Tympano-mastoid Operation (Stacke). 

The firsl incision is the same as in the simple operation, except 
that it is carried above the insertion of the auricle and then forward 
as far as a point directly superior to the anterior wall of the meatus 




Fig. 220. — Section of the Temporal Bone (Actual Size) through the Mas- 
toid Cells, Fallopian Canal, and Middle Ear. severing the Incudo-stapedial 
Articulation. 1, Membrana tympani. 2, Tip of the mallet-handle. 3, Chorda- 
tympani nerve, at the left of which is seen the canal for the tensor-tvmpani 
muscle. 4, Head of the mallet. 5, Articulating surface of anvil for the mal- 
let. 6, Aditus ad antrum, connecting the tympanic attic with the mastoid 
antrum. 7, Usual location of the mastoid antrum; but in this anomalous 
specimen there are only capacious pneumatic spaces, instead of a large cavity. 
8, Fallopian canal for the facial nerve. 9, Long crus of the anvil for articula- 
tion with the stirrup. 10, Large cavity, or antrum, in the tip of the mastoid 
process, another anomalous condition, with a thin shell of bone forming the 
cortex; between this antrum and 7, where the antrum should be normally, 
is a series of large cells connecting the two portions. 11, Articulating surface 
of the stirrup for the anvil. 







Fig. 221. — Section of the Temporal Bone (Natural Size) through the Mid- 
dle Ear, Fallopian Canal, Mastoid Antrum, and Cells, showing Dense Bone be- 
tween the Antrum and Cells, with no Communication between them. 1, 
Drumhead. 2, Tip of the mallet-handle. 3, Anvil, showing the long cms at 
the right for articulation with the stirrup, and the short process at the left 
which serves the purpose of an anchor to the bone. 4, Head of the mallet. 5, 
Tensor-tympani muscle and tendon. 6, Dense bone where pneumatic spaces 
are usually found. 7, Pneumatic cells in the tip of the mastoid process. 8, 
Fallopian canal, for the facial nerve. 9, The stirrup. At the right of 9 and 
at the left of the anvil is the aditus ad antrum, connecting the tympanum 
with the antrum. 



THE RADICAL TYMPANO-MASTOID OPERATION. 



505 



(Fig. 217). After the periosteum is raised to the margin of the 
meatus the periosteal end of the mastoid guide (Fig. 202) is inserted 
between the posterior wall of the osseous canal and its periosteal 
lining, and the latter is raised as far as the membrana tympani. One 
can tell when the tympanum is reached, for at that instant resistance 
ceases. The instrument is carried no farther inward, but is moved 
carefully around the whole circumference of the canal, separating 
the membranous lining and preserving its integrity. 




Fig. 222. — Horizontal Section of Temporal Bone, Cut Near Floor of 
External Meatus. (After C. R. Holmes.) a, Canal for internal carotid. 
TC, Tympanic cavity. MT, Membrana tympani. V, Bulbus of internal 
jugular vein. N, Facial nerve. LS, Lateral sinus. M, Mastoid. 

The integument is now drawn out of the canal like a severed 
glove-finger and reflected forward with the auricle so as to expose the 
bony canal and drumhead. The latter is now detached. The poste- 
rior canal-wall is chiseled away, backward into the antrum and 
inward as far as the tympanic attic (Fig. 218), removing the wedge- 
shaped portion of bone constituting the outer boundary of the attic 
(Fig. 219, -No. 4), until a bent probe, in contact with the attic-roof 
and drawn outward, meets no resistance. The whole inner wall of 
the tympanum is now exposed to view, and this cavity, the antrum, 



506 



THE RADICAL TYMPANOMASTOID OPERATION. 



and the meatus are converted into one cavity. The surgical relations 
of these parts are clearly shown in Figs. 220 and 221. The anvil is 
detached from its articulation with the stirrup (Fig. 170) and removed 
with the pincette (Fig. 169), care being taken not to dislocate the 
stirrup and thus open the vestibule. The drumhead is removed in 
its entirety, together with the mallet. This is a simple manoeuvre 




Fig. 223. — Six Weeks after Stacke Operation. (Author's Case.) 1, Point to 
apply electric current to affect superior branches of the facial nerve. 2, 
To affect inferior branches in treating facial paresis or paralysis. 



under the present conditions. All carious or necrotic tissue, granu- 
lations, or cholesteatomata are curetted away (Fig. 191). 

When the membranous canal is returned to its place it is incised 
along the median line of the posterior wall, longitudinally, up to the 
concha, where an incision at righl angles to the first is made through 
the posterior half of the circumference of the meatus. The two ic- 



THE EADICAL TYMPANOMASTOID OPEEATION. 



507 



suiting flaps are packed — the one upward and backward and the 
lower downward and backward — into the mastoid cavity. This gives 
access to one large cavity for after-treatment through the meatus. 

In this operation we have not only the lateral (sigmoid) sinus and 
dura to avoid, but the facial nerve and semicircular canals. To 
escape wounding the facial nerve, as soon as we arrive in its vicinity 
the mastoid guide (Fig. 202) is inserted into the attic, and the nar- 
row toe of the foot-plate is passed through the aditus ad antrum and 




Fig. 224. — Appearance Two Weeks after the Modified Operation. (Author's 
Case.) Healed five weeks after the operation. 



toward the antrum. The long handle is brought forward and down- 
ward over the cheek so that the end of the handle lies in a direct 
line with the lower border of the upper teeth or lip. Then the foot- 
plate falls over the Fallopian canal containing the nerve, and the 
chisel will strike the guide before it can reach the nerve. An as- 
sistant is instructed to hold the guide scrupulously in place and to 
give warning instantly if it is touched. The facial canal is some- 
times deficient or destroyed, leaving the nerve exposed. 



508 THE KADICAL TYMPANOMASTOID OPERATION. 

It is of the greatest importance to avoid in jury of the facial 
nerve, as it produces a shocking deformity of the face (Fig. 186). I 
have seen facial paralysis produced even by packing the wound-cavity 
too firmly with gauze, producing pressure on the exposed nerve. 

An anomalous position of the facial nerve renders it liable to 
injury if one chisels near the floor of the external canal. Hence, in 
certain cases the utmost care and skill on the part of the surgeon may 
not suffice to prevent facial paresis or paralysis, particularly when the 
walls of the Fallopian canal are congenitally deficient or have become 





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Fig. 225. — Post-mortem Section of Mastoid Process. (Author's Speci- 
men.) T, Tip of process. 2, Fistula below T leading into mastoid cells. 
3. Opening made by trephine, probe resting in antrum. 4, Cotton in ex- 
ternal meatus. 

impaired or destroyed by carious or necrotic processes. In using 
the middle-ear curette one should not forget that the tympanic walls 
are sometimes as thin as an eggshell (Figs. 211 and 222). The in- 
ternal carotid artery and the internal jugular vein are sometimes very 
imperfectly protected and liable to be penetrated. As one proceeds 
upward and backward the external and posterior semicircular canals 
must be avoided. 

The radical, or Stacke, operation consumes more time than the 
simple, or Schwartze, operation. The time varies with different op- 
erators from one to two hours. Longer time is required for healing 



THE MODIFIED MASTOID OPERATION". 



509 



also on account of the greater extent of wound-surface. Fig. 223 
shows progress six weeks after the Stacke operation. 

The Modified Mastoid Operation. 

In this operation the incision is the same as in the radical one 
(Fig. 2 IT). The writer does not dissect out the whole integumentary 
canal, but separates only its postero-superior half from the bony wall 




Fig. 226. — Appearance Three \\ eeks after a Modified Stacke and an 
Operation for a Xeck-abscess. The latter is healed and the former kept 
open until the wound-cavity filled with healthy tissue. Patient dis- 
charged cured fifty-five days after operation. 

and then depresses it sufficiently to give easy access to the tympanic- 
cavity. By this means one-half of the soft meatus is left undisturbed 
and the integrity of the integumentary canal is preserved. This 
method leaves a less extensive wound to heal, and it has afforded the 
most satisfactory results. The collapse of the canal can be prevented 
by lightly packing the mastoid wound and by packing the canal or 
inserting a firm-rubber tube. In other respects this method, which 



510 



THE MODIFIED MASTOID OPERATION. 



the author has preferred for several years, corresponds to the Stacke 
operation. 

It is safer not to close the wound entirely until it has healed 
from the bottom. When the interior has rilled with firm cicatricial 
tissue up to the surface of the bone-opening it is safe to allow it to 
close. We have had good results after closing the wound completely 
at the end of the operation, but it is certainly not so safe a plan. 




Tig. 227. — Abscess of the Mastoid Process Extending over Ten Weeks, re- 
sulting in an Enormous Abscess of the Neck, reaching Nearly to the 
Thoracic Cavity. (Author's Case.) Cured by an operation. 



The best dressing is one of dithymol diiodide (aristol) sprinkled 
over the wound-surfaces, covering them entirely. Then iodoform 
gauze should be placed lightly in that part of the wound chosen to 
remain open. It should not be packed down to the bottom of the 
wound so firmly as to crowd any discharge inward, but it should fill 
the cavity and keep the cutaneous tissues from closing over the super- 
ficial opening in the bone. Dithymol diiodide has two excellent 



THE MODIFIED MASTOID OPERATION. 



511 



qualities: it is the best cicatrizant we possess, and it has the additional 
advantage of being to some extent an anaesthetic. While iodoform 
is irritant and toxic and boric acid sometimes produces pain, dithymol 
diiodide soothes without any ill effects. 

After stitching that part of the wound to be closed, and dress- 
ing its open mouth for drainage, the whole is covered with sterilized 
gauze, absorbent cotton, and a net bandage. This bandage is made of 




Fig. 228.— The Same as Fig. 227, showing the Outline of the Swelling. 

the common white mosquito-cloth, which, as used in the Northern 
States, is sized with a preparation of glue. The roll of bandage is 
dipped in sterilized water just before applying, until it is wet through. 
Then the water is squeezed out and the bandage is applied as usual. 
When it dries, the layers adhere together firmly, so as to retain their 
position for several days in succession without any attention. 

This operation requires more time than Schwartze's and less than 
Stackers, both to perform and for healing. Fig. 224 shows progress 



512 ABSCESS OF THE XECK. 

two weeks after the modified Stacke operation. Three weeks after 
the operation taste was suddenly lost, but returned again. The ex- 
uberant granulations seen on the right border of the wound were re- 
pressed with silver-nitrate stick. 



Abscess of the Xeck fro:\i Middle-ear axd Mastoid 

Suppuration. 

This is an occasional complication that requires operative in- 
terference. It arises .from the purulent process penetrating the bone 
and burrowing beneath the superficial or deep layer of muscles. If 
it break through the inferior wall of the tympanic cavity, the pus- 
channel may extend along underneath the deep layer of muscles even 
to the thoracic cavity. If it rapture through the anterior wall of the 
middle ear, a retropharyngeal abscess or a superficial cervical abscess 
may develop. When the pus breaks through the inferior surface of 
the mastoid process (Fig. 225), it burrows under the sterno-mastoid 
muscle and forms a swelling on the side of the neck. At first the 
tumor is small, is generally located directly below the lobule of the 
auricle, is hard to the touch, and may give so little evidence of its 
presence that it may be overlooked. 

So slight are the symptoms at first that patients do not mention 
the neck trouble, and it is only by the habit of close observation that 
the surgeon himself does not let so serious a matter escape him. 
"While no active symptoms referable to the neck-abscess may occur 
during the first few days, it often increases rapidly in size. The sur- 
rounding tissues become infiltrated; the tumefaction extends over a 
larger surface; the overlying skin becomes tense and shiny to such a 
degree as to suggest erysipelas; the movements of the head become 
restricted and painful; the temperature rises; the tongue becomes 
coated; headache, loss of appetite, and other febrile disturbances su- 
pervene. Although fluctuation does not occur early, especially if the 
abscess is deep-seated, the diagnosis is promptly suggested by the pres- 
ence of the suppuration above it. 

The only treatment is to open and evacuate the cavity and treat 
it antiseptically until pus formation ceases. Great care must be taken 
to avoid injury to tie' network of veins, arteries, and nerves in this 
region. For this reason it is best to open the abscess as far back as 
possible, and yet open it in a dependenl position. Further treatment 
should be on general surgical principle-. 



ABSCESS OF THE NECK. 513 

Fig. 226 shows such a case three weeks after the modified Stacke 
operation and opening of the neck-abscess, the latter being entirely 
healed. A drain age-tube was inserted into the neck-opening, carried 
upward, and brought out through the mastoid wound. 

Figs. 227 and 228 show an extraordinarily large abscess of the 
neck complicating mastoid and middle-ear suppuration. The swelling 
over the mastoid process is best shown in the front view. The great 
swelling of the neck is indicated by the curved line below the ear in 
the posterior view. 



CHAPTER XLIII. 

DISEASES OF THE INTERNAL EAR. 

As compared with affections of the middle ear, diseases of the 
labyrinth are rare, except as sequels of tympanic diseases. The 
methods of making a differential diagnosis of diseases of these two 
parts of the ear are sufficiently set forth in the section on hearing- 
tests. 

Hyperemia and Anemia of the Labyrinth. 

Hyperemia may occur as a result of middle-ear inflammation or 
some intracranial disease, or secondarily to a disturbance of the cir- 
culation in the blood-vessels of the neck, such as pressure on the large 
veins, or it may be due to certain medicines, — quinine, sodium sali- 
cylate, amyl nitrite, etc. It sometimes complicates the fevers. 

Anaemia of the labyrinth may follow great haemorrhages, exhaust- 
ing affections, and various anomalies of the circulation. 

The symptoms need not necessarily include impairment of hear- 
ing, but tinnitus aurium and giddiness are the principal manifesta- 
tions. These conditions will be recognized as accompaniments to the 
main diseases which give rise to them, and the diagnosis, prognosis, 
and treatment will be determined accordingly. If hyperaemia is due 
to active inflammation of the middle ear, the measures laid down in 
the section on that subject should be brought into requisition: co- 
caine, local bleeding, counter-irritation, catharsis, bromides, rest, the 
aural icebag (Fig. 194), etc. 

In anaemia of the labyrinth the primary condition that causes 
the anaemia will suggest the treatment. 

Inflammation of the Labyrinth (Otitis Interna). 

Primary inflammation of the internal ear is of very rare occur- 
rence; but a disease of the surrounding structures, the middle ear, 
or mastoid process may extend to the labyrinth. An intracranial 
(514) 



INFLAMMATION" OF THE LABYRINTH. 515 

lesion also ma}- involve this organ. Predisposing causes are to be 
found in the loss of the stirrup, caries and necrosis of the inner wall 
of the tympanic cavity, etc., by means of which an entrance of bac- 
teria and discharges is effected into the labyrinth. 

Cases of primary labyrinthitis have been reported by Agnew, 
Schwartze, Webster, and others. Occasionally cases are seen in which, 
after a severe cold or some other cause, or even without any dis- 
cernible cause, sudden deafness of greater or less degree comes on, 
without traces of middle-ear disease. Giddiness usually accompanies 
such attacks. The dizziness may disappear, leaving a permanent deaf- 
ness. In case this deafness is due to a serous exudation into the laby- 
rinth, producing pressure on the terminal filaments of the auditory 
nerve, the loss of hearing may not be complete or permanent. Ab- 
sorption of the exudate may be followed by a clearing up of the 
subjective symptoms and deafness. 

Purulent inflammation is of more serious import, since it not 
only robs the sufferer of the power of hearing, but jeopards his life. 
Besides the predisposing causes mentioned above, it is sometimes a 
result of the eruptive fevers, diphtheria, mumps, variola, typhoid 
fever, or cerebral meningitis. The latter disease is simulated by the 
most active form of primary labyrinthitis. The two are easily mis- 
taken for each other, the symptoms are so similar, but the duration 
of the labyrinthal affection is but a small fraction of the other. 

Panotitis, or inflammation of both middle and internal ears, is 
generally the result of scarlet fever or diphtheria, producing irrep- 
arable deafness and for some time a staggering gait. A separate 
description of this disease is not necessary, since it is a combination 
of two conditions already presented. 

The prognosis of inflammation of the labyrinth is unfavorable. 
Some cases recover; more do not. One such case, complicated with 
mastoiditis, recovered entirely after four months, without mastoi- 
dectomy, although I was in doubt for a time if further postponement 
of the operation were justifiable. Another became entirely deaf dur- 
ing meningitis at the age of 2 years. During the sixth year she began 
to distinguish sounds. She has improved under treatment, and has 
learned to talk without special instruction or lip-reading. At the 
age of ten years improvement continued. She heard conversation 
well, and attended the public schools. The author has met with a 
number of such instances; yet it is safest to give a very guarded and 
conservative prognosis. 



516 Meniere's disease. 

Treatment. — Potassium iodide, pilocarpine, iodine ointments, 
etc., have been used by Politzer, Moos, Gruber, and others. Of a 
2-per-cent. solution of pilocarpine hydrochlorate, from 2 to 6 drops are 
injected into the forearm daily, in increasing doses. General anti- 
phlogistic treatment must be resorted to in the acute stage, such as is 
detailed in the division on acute inflammation of the middle ear. 
In syphilitic infection the iodides and pilocarpine are indicated. In 
suppuration the methods given for middle-ear suppuration are ap- 
plicable. 

HAEMORRHAGE INTO THE LABYRINTH. 

Extravasation of blood into the labyrinth may take place as the 
result of the same diseases that induce inflammation of this organ, 
as well as from atheromatous degeneration, fracture of the temporal 
bone, concussion, and necrosis. Eesolution may take place by absorp- 
tion, or an inflammatory process may be set up, with its train of con- 
sequences, or the clot may undergo organization. 

Meniere's Disease. 

Meniere first described a group of symptoms that characterized 
a case of effusion of blood into the labyrinth: deafness, vertigo, and 
vomiting. The attack comes on suddenly, the patient falling as in 
an epileptic seizure and presenting an appearance, on regaining con- 
sciousness, similar to one coming out of an epileptic fit. In addi- 
tion to the symptoms mentioned, there may be subjective noises and 
total deafness. After consciousness returns and vomiting ceases, the 
great deafness, dizziness, and tinnitus aurium remain. Walking with 
the eyes closed is difficult and the body may incline toward one side. 
The mental faculties evince impairment. 

Diagnosis. — This is based on the suddenness of the attack; the 
extreme loss of hearing without previous serious disturbance of func- 
tion; the presence of a group of symptoms pointing, in unison, 
toward aural disease; absence of disease of the conducting apparatus 
or of any other structure than the auditory nerve. 

Prognosis. — This, for the most part, is unhappy. The hearing 
may improve, but this is not likely. The dizziness soon diminishes 
sufficiently to allow the patient to walk, though' unsteadily, and he 
staggers toward the side of the affected ear. The tinnitus may dis- 
appear, but is likely to continue indefinitely. 



SYPHILIS OF THE LABYRINTH. 517 

Treatment. — Eest in bed and perfect quiet are important. The 
bowels should be relaxed, an icebag (Fig. 194) applied to the mastoid, 
and a counter-irritant to the side and back of the neck. Potassium 
bromide and iodide in large doses and pilocarpine may be employed 
as directed for labyrinthitis. Charcot recommended quinine, but, 
since it produces labyrinthal congestion, it appears to the writer to 
be contra-indicated. 

Leucocyth^mic Deafness. 

Patients suffering from leucocythsemia are sometimes subject to 
sudden and complete deafness and vertigo, and even facial paralysis. 
The ear, like all other organs, is subject to hemorrhagic and ex- 
udative processes, although it is not as frequently implicated as the 
e3^e. Inflammation may follow, resulting in proliferation of connect- 
ive tissue or bony growths. 

The Treatment consists in measures for the general condition 
and the remedies recommended in Meniere's disease. 

Syphilis of the Labyrinth. 

Syphilitic lesions of the labyrinth are most likely to occur dur- 
ing the tertiary stage, but sometimes manifest themselves in the sec- 
ondary period. The precise pathological changes in this disease are 
not yet clearly established. The symptoms are very similar to those 
characterizing Meniere's disease. In most cases subjective noises are 
added to the great deafness and dizziness. The affection is usually 
bilateral. Bone-conduction is diminished or destroyed. The presence 
of syphilitic lesions in other parts of the body, or a history of a 
previous infection, combined with the symptoms referred to, clear up 
the diagnosis. Of all children with inherited syphilis, 10 per cent, 
have ear trouble (Hutchinson and Jackson). Others claim as high 
as 33 per cent. The characteristic Hutchinson teeth should be 
looked for. 

The prognosis is unfavorable. In recent affections and in young 
persons the prospects are more encouraging than in the severe types, 
with age and a generally impoverished condition to combat. 

Treatment. — This is the same as for constitutional syphilis, with 
the addition of pilocarpine injections, in 2-per-cent. solution, of -I 
to 12 drops in increasing daily doses. Any improvement to be had 
from the pilocarpine should show within two weeks. Edmund D. 



518 LEUKOSES OF THE PERCEPTIVE APPARATUS. 

Spear speaks highly of the results from subcutaneous injections of 
pilocarpine. The writer generally employs the mixed treatment, — 
mercury and potassium iodide combined. 

Albert H. Buck cites a case of congenital syphilitic disease of 
the ears in a boy, giving rise rapidly to a high degree of bilateral 
deafness. The hearing was much benefited by treatment, which fact 
led the reporter to conclude that it was an instance of localized peri- 
ostitis affecting either the internal surface of the cochlea or the 
articular borders of the stapes and oval foramen. 

Toeplitz reported a case of aural syphilis in which "the labyrinth 
was affected primarily in the course of a freshly acquired case of 
syphilis. The aural affection began simultaneously with the appear- 
ance of roseola. 

"The special features of this case are as follow: 1. The affection 
of the labyrinth occurred after the appearance of pharyngeal patches 
and simultaneously with the appearance of roseola. 2. The aural 
lesion took place during the secondary stage without attacking the 
middle ear. 3. The diagnosis of syphilis was made from the ear 
trouble. 

"The pathological changes produced by the syphilitic poison, 
which entered the lymphatic and blood-current of the labyrinth from 
the pharynx through the aqueduct and the blood-vessels, probably 
consisted in inflammatory alterations of the membranous portion, the 
periosteum and the surrounding lymph of the vestibule, and the first 
turn of the cochlea, with an increase of cellular elements and haem- 
orrhages. All these changes disappeared after energetic antiluetic 
treatment." 

Diseases of the Auditory Xerve. 

The acoustic nerve may become the seat of various changes — 
hyperemia, hypertrophy, atrophy, secondary inflammation, and sup- 
puration — through invasion from the contiguous intracranial or tym- 
panic structures. It must be admitted that the present state of our 
knowledge of these pathological processes affords no basis for a prom- 
ising system of treatment. 

neuroses of the perceptive apparatus. 

Hyperaudition. — A transitory increase in the intensity of the 
hearing-power affects some persons. For this condition the author 
proposes the term hyperaudition as conforming to our system of 



SUBJECTIVE SOUNDS. 519 

nomenclature and as being correctly and briefly expressive. This con- 
dition is a symptom of cerebral excitement or irritation, and may 
constitute a precursor of intracranial disease. 

Hyperesthesia. — Auditory hyperesthesia is an insufferable sen- 
sitiveness to sounds or noises. Highly nervous subjects often present 
this anomaly, and it is an accompaniment of headaches and intra- 
cranial affections. It is often observed in sclerosis of the middle ear. 
The slamming of a door, the firing of a gun, etc., cause much more 
discomfort than in a state of health. 

Paracusis. — This is a false perception of the pitch of sounds. 
The tone is heard by air-conduction generally higher than its true 
pitch, but may be heard lower. This may occur in one ear only, even 
when both are affected by sclerosis, and it is due to an abnormal ten- 
sion of the transmitting mechanism. The writer has observed in such 
cases that certain tones only, and usually the higher, were thus incor- 
rectly perceived by one ear, both being similarly diseased, while all 
tones were correctly heard by bone-conduction. The apparent altera- 
tion in pitch varies in different subjects from one-quarter to one-half 
tone, or even one or two tones. This trouble unfits a musician for any 
but solo-playing, and it may incapacitate him for that. 

Double hearing has been observed in acute middle-ear inflamma- 
tion. The tone was perceived as a primary, accompanied or followed 
by a secondar}^, sound, the latter being in the nature of an echo. This 
may be due to hearing correctly with the normal ear and incorrectly 
with the other. 

Paracusis Willisii. — This is hearing better in a noise, and is 
pathognomonic of sclerosis. It is undoubtedly due to the fact that, 
when powerful sound-waves set the ossicles in vibration, the lesser 
vibrations are carried along with the greater to the perceptive organ. 
Once arrived at the latter point, the smaller waves are recognized with 
the larger (see chapter on "Sclerosis"). 

Subjective Sounds. — These are sounds experienced by the patient 
as real, but existing only in his own consciousness. They are not 
always referred to the ears, but to other parts of the head: the region 
immediately above the ears, the occiput, and even the vertex. They 
are due to irritation of the auditory nerve and possibly of the hear- 
ing-centre. Occasionally they are so intense that the sufferer is led 
to believe them to be objective sounds and that his friends ought to 
hear them by placing their ears close to his. They may become so 
unendurable as to cause melancholia and loss of sleep and memory. 



520 SUBJECTIVE SOUNDS. 

Even in greatly impaired hearing and total deafness patients have 
declared to me that they would not care whether the treatment bene- 
fited the hearing, if only the interminable head-noises could be 
stopped. 

It is sometimes imagined that insects have gained entrance into 
the ears, and the surgeon is importuned repeatedly to look for them, 
being assured that they must be found. One woman persisted in her 
declarations that there were crickets in her ears, for she could hear 
their constant chirping. Notwithstanding my examinations, and 
statements to the contrary, she filled her ears with spirit of turpentine 
to kill the crickets. 

Very susceptible individuals may have their minds unbalanced 
by this harassing, unceasing din. We have seen instances in which 
subjective voices were heard, but they were hallucinations of hearing 
in persons of unsound mind. Whether the psychoses were attribu- 
table to the ear disease or whether the latter was merely a coincident 
could not be determined. The latter was probably true, and in such 
cases the tinnitus aggravated the mental aberration. Ear treatment 
may afford much relief in such nervous affections by removing the 
excitant of hearing-hallucinations. 

There is a wide variation in the character of the subjective 
noises. Most people call it a ringing or tinkling of high pitch. 
In others it is like the roaring of water, the sighing of the winds, the 
rumbling of wagons, crackling or explosive sounds, or sudden changes 
from the usual ringing to a loud breaking forth of a tone, as if a 
small bell had been struck a hard blow. The pitch of the ringing 
in one ear may be in unison with a fork of 2048 vibrations, or the 
third C above middle C of the piano, while the pitch of the tinnitus 
of the other ear may be much lower and the sound of a different 
quality. Probably in most cases it is like' the ringing produced by 
overdoses of quinine. There may be two different qualities of sounds 
in the same ear. 

The noises are increased during a combination of low barometer 
with low thermometer, especially so when the air is very humid. 
Continuous cloudy or rainy weather and winds give rise to them. 
The same is true of quinine, sodium salicylate, alcoholic beverages, 
excessive tobacco-smoking, loss of sleep, sneezing, coughing, much 
use of the voice, very cold drinks or food, and a damp, cold, moldy 
atmosphere, such as is found in basements. On the other hand, warm, 
sunshiny weather diminishes- the noises. They are less observed or 



SUBJECTIVE SOUNDS. 521 

entirely suppressed in the presence of objective sounds like those of 
an orchestra, the noises of the street or cars, etc. Often patients can- 
not tell whether or not the noises are present when objective sounds 
can be heard. When tinnitus first appears it may be intermittent, but 
in advanced sclerosis it becomes interminable. A certain tolerance 
of the noises is frequently acquired, so that they are not very much 
noticed when the individual is preoccupied or in a noisy locality; but 
in quiet surroundings the noises seem to besiege the brain again with 
redoubled intensity. 

Nervous tinnitus aurium is an affection in which the ear is not 
of necessity involved. It may arise from reflex causes and requires 
general, rather than special, treatment. However, the ear should be 
inspected for any possible lesion. 

Spasmodic noises, or those occasioned by spasmodic contractions 
of the muscles of the ear, are rare. In one case I could plainly see, 
synchronously with the clicking noises, a rhythmical movement of 
the drumhead, — excursions inward and outward, — undoubtedly oc- 
casioned by spasmodic contractions of the tensor tympani muscle. 
Spasmodic contractions of the Eustachian tubal muscles may cause 
snapping sounds. Mucous rales occur in the Eustachian tube and 
middle ear in the same manner as they do in the bronchial tubes. 
Circulatory disturbances of the heart, the internal carotid artery, or 
the arteries of the ear give rise to pulsating sounds in unison with 
the pulse. 

Prognosis. — This depends principally upon the cause of the sub- 
jective sensations, but, excepting in sclerosis and diseases of the laby- 
rinth and of the brain, the prospect of relief is good. The longer the 
noises have existed, and the more unvarying and continuous their 
character, the less promising is the prognosis. 

Treatment. — Since tinnitus aurium is a symptom of various 
pathological processes, we can speak of its treatment here in a gen- 
eral way only, otherwise it would involve the measures necessary for 
the special treatment of all the causative conditions. These will be 
found in their proper divisions of the subject. 

It is much more difficult to stop the noises than to improve the 
hearing. The latter often increases, while the noises prove intract- 
able. We may diminish the noises or change their character, while 
we cannot by any known means eradicate them, in many cases. It 
is unwise to promise to cure or even to diminish them. In the ma- 
jority of instances the tinnitus is a symptom of sclerosis. In addi- 



522 PAEESIS AND PAEALTSIS OF THE AUDITORY NERVE. 

tion to the treatment outlined for sclerosis the author has used coun- 
ter-irritation with mustard or its oil, and has vesicated with can- 
tharidal collodion. These applications sometimes produce a bene- 
ficial effect. When the tinnitus has continued after an acute inflam- 
mation of the middle ear has subsided, we have found medium doses 
of sodium bromide afford complete relief. This was attributed to its 
sedative effect on the labyrinthal irritation. Charcot and Guye have 
recommended quinine. It may prove serviceable in periodical tin- 
nitus, but as it produces congestion of the middle ear and labyrinth, 
and, in large or continued doses, deafness, its utility in ear affections 
is very limited. 

Paresis axd Paralysis oe the Auditoey Neeve. 

There are certain forms of paresis and paralysis of the auditory 
nerve that are so rarely met with as to merit only a passing notice in 
a work Of such practical brevity as this. In some hysterical subjects 
anomalies of hearing and subjective noises occur, but in association 
with anaesthesia or hyperesthesia of other parts of the body that 
indicate the character of the affection. These attacks are transitory 
and without apparent changes in that part of the ear that is ac- 
cessible to inspection. 

Treatment of these aberrations is largely based on the associated 
causative conditions; but, in addition to the general treatment, spe- 
cial measures may be employed by means of the ear-electrodes (Fig. 
188). The writer has generally preferred the primary current of a 
faradic battery to the galvanic, for the former unites the properties of 
both currents, as he has shown in his batteries by means of the gal- 
vanometer. The negative pole is connected with the electrode that 
rests in the ear which requires stimulation or irritation. The current 
is turned on very mildly at first and gradually strengthened until it is 
as strong as can be comfortably borne, and continued for from six to 
ten minutes. By means of my electrodes the current is more limited 
to the ear than with the older kinds, which diffuse the current usually 
over the side of the head. 

In using these electrodes it is not necessary to fill the meatus 
with water, as was the former custom, to the detriment of the drum- 
membrane, but the tips of the electrodes are moistened and covered 
with a moist layer of absorbent cotton. 

In treating paresis or paralysis of the facial nerve after a mas- 
toid operation the wound can be filled with wet cotton and the elec- 



CEREBRAL CAUSES OF DEAFNESS. 523 

trode placed in contact with it. This conducts the current to the 
injured nerve. The other electrode is held in contact with the op- 
posite mastoid process. During a part of the treatment the electrode 
is removed from the opposite side and applied to the groups of mus- 
cles affected (Fig. 223). 

Cerebral Causes of Deafness. 

Cerebral deafness may arise in two ways: by a disease of the hear- 
ing-centres or by an extension of a disease of the brain or of the 
meninges to the origin or course of the acoustic nerve or to the laby- 
rinth. The most frequent cause of intracranial deafness is menin- 
gitis. The loss of hearing may not become apparent at the time that 
it occurs, but it will be discovered when the patient regains conscious- 
ness. The destruction of hearing takes place within the first few 
weeks of the disease. This form of deafness is hardly amenable to 
treatment, the reason for which is apparent when we consider the 
pathological processes that destroy the function of the nerve: "Sof- 
tening or thickening of the ependyma of the fourth ventricle, puru- 
lent infiltration and softening of the auditory nerve' 7 (Knapp); "im- 
bedding of the latter in meningeal exudation" (Schwartze); "shrivel- 
ing of the nerve-stem, and purulent inflammation of the membranous 
labyrinth, the origin of which can be traced to transmission of the 
inflammation either along the sheath of the auditory nerve (neuritis 
descendens) or through the aqueducts" (Politzer). 

The majority of cases of deaf-mutes coming under my observa- 
tion in which the deafness was acquired were the result of meningitis. 
Politzer and Moos observed a staggering gait in half or more of their 
cases. We have not been able to verify the statement that tinnitus 
annum is a frequent symptom, but most of my cases of deaf-mutes 
have been children, and they rarely speak of subjective noises. 

Treatment will be considered only briefly, for its effects are 
unsatisfactory. If the patient is seen during the meningitis, the ice- 
bag (Fig. 194) should be applied over the ear as soon as there are 
aural symptoms. Later, if the deafness is not of too long standing, 
absorbents and alteratives should be tried, such as potassium iodide, 
and pilocarpine in a 2-per-cent. solution, from 6 to 10 drops at an in- 
jection. 

Many pathological processes in the brain are capable of disturb- 
ing the hearing. It has been observed repeatedly that a disease of the 
left temporal lobe, involving the first convolution, produces word- 



524 NEW GROWTHS OF THE INTERNAL EAR. 

deafness. In this peculiar state there is hearing for sounds, but in- 
capacity for interpreting the compound sounds entering into the 
formation of words. This circumstance would tend to locate the 
cortical centre for hearing in this part of the brain. 

The most frequent cerebral cause of deafness is the presence of 
tumors. The symptoms are very like those of labyrinthal disease: 
dizziness, tinnitus, varying degrees of deafness, and gastric disturb- 
ances. 

The diagnosis is often impossible. In the case of a tumor, how- 
ever, facial paralysis may develop, and bone-conduction may not be 
obliterated as it is in the labyrinthal deafness. Tumors may also 
produce pressure affecting other nerves besides the acoustic or facial. 
Anaesthesia of the skin of the corresponding side of the head is some- 
times found. Symptoms pointing to involvement of the optic or other 
nerves may aid in arriving at a correct deduction. 

New Growths of the Internal Ear. 

New growths of primary formation in the internal ear have been 
met with but very infrequently, and clinically their consideration 
merits only brief mention. The presence of growths in this situation 
is usually due to an extension of epithelioma or sarcoma from the 
cranial or tympanic cavity. 



CHAPTER XLIV. 

DISEASES OF THE INTERNAL EAR (Concluded). 

Injuries to the Labyrinth. 

Penetrating wounds of the labyrinth are of infrequent occur- 
rence, but more often damage is done by fractures of the temporal 
bone, and concussion transmitted through the bones or through the 
air and conducting apparatus to the labyrinth. 

The symptoms of fracture of the bone are: a flow of blood and 
serous fluid from the ear, inco-ordination, deafness, and vertigo. The 
symptoms of concussion are the same, with the exception of the bloody 
and serous discharges. The author has seen quite a number of in- 
stances in which the symptoms of irritation or paralysis of the audi- 
tory nerve supervened upon blows on the skull or on the ear. In 
the latter, rupture of the drumhead generally was present when the 
cases were seen early, and in such instances the labyrinthal symptoms 
were not as severe as when the drumhead was not ruptured, for in 
the latter case the force of the concussion was spent principally on the 
stirrup, probably impacting it into the oval window. I have exam- 
ined many soldiers of the war between the States, who suffered more 
or less loss of hearing from concussions produced by cannons, ex- 
ploding shells, etc., in battle. Instances have also come under my 
observation in which blows on the head from the "sandbags" of rob- 
bers, and from other weapons, and concussions from falls, have pro- 
duced total deafness. Many workers in boiler-shops have appeared 
at the clinics with great dullness of hearing and tinnitus. Their ears 
were generally full of hardened, impacted plugs of black wax. After 
removing these the impairment of hearing still remained of high de- 
gree. Blacksmiths, tinsmiths, coopers, and iron-workers suffer simi- 
larly. This is due to the constant concussions of the drumhead, 
ossicles, and intralabyrinthal fluid and the auditory nerve from their 
incessant hammerings. The effect is to produce, in addition to the 
labyrinthal affection, the sclerotic form of middle-ear catarrh, which 
has already been considered. 

(525) 



526 DEAF-MUTISM. 

Treatment of these forms of disturbances of hearing, of co- 
ordination, etc., is generally of little or no avail if several months or 
years have elapsed since the injury. In the early stage succeeding 
the concussion, the treatment laid down for tinnitus aurium and for 
paralysis of the acoustic nerve is indicated. 

"J. A. Stucky, of Kentucky, reported a fracture of the base of 
the skull, producing deafness, tinnitus, vertigo, exophthalmos, facial 
paralysis, mastoiditis, aphasia, and unsteady gait, with recovery after 
a modified Stacke operation." ("Year-book of the Xose, Throat, and 
Ear," 1900.) 

Deaf-mutism. 

This is the lack or loss of speech due to congenital or acquired 
deafness. In my experience it is a rare condition. Only 1 / 2 of 1 per 
cent, of all the cases of ear-defects that the writer has studied in 
hospital, dispensary, and private practice are of the deaf-mute class. 

Pathology. — In congenital deaf-mutism the precise condition to 
which it is due cannot be determined. This subject presents an op- 
portunity for the application of the theory of reversion as affect- 
ing types of degeneracy. It may be due to lack of development in 
some part of the organ of hearing, deformities of the fenestras of 
the labyrinth, hydrocephalus, or pathological changes in the course 
or origin of the acoustic nerve. The acquired form may be due to 
middle-ear sclerosis, necrosis of the labyrinth, auditory neuritis, men- 
ingitis, or cerebritis. The tympanic and labyrinthal cavities may be 
entirely obliterated by connective-tissue and osseous proliferation. 
If the hearing is lost under the fifth year there is no speech, because 
it has not been acquired, while speech which has already been ac- 
quired later in life may be more or less perfectly retained after hear- 
ing is lost. However, I have many times observed that even in deaf- 
mute infants the primitive words "mamma" and '"papa" only are 
uttered. 

I have known dumbness to follow the loss of hearing even after 
speech was acquired. The ability to articulate words gradually de- 
clined until nothing more than mumbling and mouthing of unin- 
telligible sounds remained. In about 50 per cent, of deaf-mutes the 
semicircular canals are affected, which accounts for their peculiar 
straddling gait, the feet being kept wide apart, and for their inability 
to stand with their eyes closed, and especially on one foot. 






DEAF-MUTISM. 527 

Among the 158 deaf-mutes of the institution for this class at 
Prague, Frankenberg {American Medico-Surgical Bulletin, December 
10, 1897) found 94, or 59 per cent., with adenoid vegetations in the 
vault of the phar}'nx large enough to fill this space. Of these, 56 
were boys and 38 girls. In 69 of these cases there were anomalies of 
the ears as follow: Impacted cerumen, 24; chronic suppuration with 
granulations, 14; sunken drumhead, 12; stenosis of the external 
meatus, 1; atresia of the meatus, 1; foreign body in the meatus, 1; 
adhesion of the drumhead to the internal wall of the middle ear, 1; 
hyperemia of the drumhead, 4; dry perforation of the drumhead, 
3; absence of the membrana tympani due to suppuration, 4; polypi, 
3; mastoid cicatrix from periostitis, 1. Of these cases, 37, or 53.6 
per cent., had adenoids. 

These facts indicate the importance of examining for these 
growths in children having ear affections. xArslan found 6 deaf- 
mutes among 426 cases of adenoids, and cured one and relieved 
another, with respect to both the hearing and speech, by the adenoid 
operation. 

In 118 autopsies on deaf-mutes performed by Mygind there were 
evidences of middle-ear diseases in 79. There were only 19 that were 
free from pathological conditions of the labyrinth or nervous centres. 
"In most of the cases the changes were clue to severe and extensive 
inflammations, especially in acquired deaf -mutism. Other anomalies 
were almost identical in the two classes of cases, congenital and ac- 
quired. The opinion hitherto accepted that deaf-mutism results from 
congenital deafness, due to some anomaly of development of the 
organ of hearing, is invalidated by the fact that anomalies are of 
very great variety. Changes usually affect both ears, though un- 
equally. The middle ear has been found most often affected. The 
internal ear was affected most in the semicircular canals, rarely in the 
vestibule; and in a great number of deaf-mutes these anomalies could 
be considered the chief cause of the deaf-mutism. In some cases the 
auditory nerve presented phenomena of atrophy and degeneration, 
but more often the nerve was intact. In some cases there were anom- 
alies of the brain." {Medicine, January, 1898.) 

Etiology. — Congenital deaf-mutism may be due to heredity, but 
it is not a frequent occurrence. A constitutional predisposition to this 
defect exists in some families, several members of which are afflicted. 
In one family the healthy parents had five daughters with normal 
senses and six sons who were born deaf (Kramer). Among all the 



528 DEAF-MUTISM. 

deaf-mutes the writer has examined he does not know of one whose 
parents were deaf-mutes, although some have had various middle-ear 
affections. Consanguineous marriages, as well as specific disease and 
intra-uterine influences, are believed to account for deaf-mutism in 
quite a large proportion of instances. The acquired form may follow 
injuries during childbirth or infancy, meningitis, scarlatina, typhoid, 
diphtheria, mumps, syphilis, or inflammation of the labyrinth. I have 
not seen the epidemic influenza, or grip, given as a cause, but I have 
had occasionally under treatment the case of a girl, 6 years old, who 
had lost her hearing entirely for four years in consequence of an at- 
tack of the grip. Under treatment the hearing returned sufficiently to 
enable her to hear ordinary conversation and to learn to speak intel- 
ligibly. Inspection revealed no change in the drum. 

Symptomatology. — In infants the defect is not likely to be dis- 
covered until about the time that children begin to talk,, and even 
then it may be overlooked by the parents, who attribute the back- 
wardness to slow development. . We have often observed that parents 
believed their children could hear and that some defect in the organs 
of speech accounted for its absence, and yet they were born deaf- 
mutes. Failure to respond to sounds and calls can be easily detected 
if tests are made in such a manner as not to attract the child's at- 
tention by movements within the range of vision. Calling its name 
from behind, clapping the hands in such a position as not to pro- 
duce waves of air that will strike the child, and out of its sight, the 
tuning-forks (Fig. 120), the Delstanche whistle, etc., are conclusive. 
If the child hear vowel or other sounds, a change of expression, a 
lighting up of the countenance, smiles, etc., evince the fact. 

Diagnosis. — The means of diagnosis have been indicated above. 
In a large proportion of cases a modicum of hearing is present. The 
ability to say "mamma" is not significant, since it is frequently pres- 
ent in hopeless cases. Such sounds are primordial and are uttered 
by the lower animals. 

Prognosis. — While the writer has seen apparent improvement in 
a few cases of congenital deaf-mutes, it has not been of such a degree 
as to admit of understanding the common conversational tone. Loud 
sounds and some words could be appreciated, without doubt, but even 
this slight gift proved a pitiful source of happiness. A few cases are 
on record in which there was a useful development of the hearing 
after about the sixth year or after puberty. The acquired form is 
generally regarded as less promising still. 



DEAF-MUTISM. 529 

Treatment. — In many cases examined by me there were evi- 
dences of middle-ear dry catarrh, but whether this bore any signifi- 
cant relation to the absence of hearing-power was a debatable ques- 
tion. It is possible that middle-ear disease in early infantile life may 
have involved the labyrinth in a destructive inflammatory process; 
or, if the labyrinth has escaped, connective-tissue proliferation or 
osseous growths may have obliterated the round window and may 
have anchored the stirrup in the oval window so firmly as to pre- 
clude the possibility of its vibratory movements in response to sound- 
waves. If the auditory nerve is not destroyed, bone-conduction of 
sound can be demonstrated. In that case inflation of the middle 
ear and the application of the massage otoscope (Fig. 114), together 
with the galvano-faradic current (Fig. 188), may demonstrate the pos- 
sibility of improvement after a few weeks. In one case of a young 




Fig. 229. — The Conical Conversation- tube. 

man with greatly thickened and retracted drumheads, I resected 
parts of them, which resulted in a considerable improvement. He 
had already been able to perceive the sounds of the vowels, and after 
the operations he acquired the use of quite a number of words be- 
fore leaving the city. 

Special instruction of deaf-mutes should begin as soon as it is 
shown that there is no hope for the hearing. The younger the pupil, 
the greater the accomplishment in the schooling. During the World's 
Fair in Chicago great proficiency was shown in the attainments of 
very young children in lip-reading and articulate language in the 
school-exhibits of those who had never heard. The perfect discipline 
was something to be appreciated by those who have had much ex- 
perience with the deaf-mute class. Indeed, the author has often been 
led to a correct diagnosis in deaf-mute children before an examina- 
tion was made, and before any information was imparted, by their 

34 



530 DEAF-MUTISM. 

irritable temper and incoherent violent actions. Lip-reading and 
articulate speech should always be taught them, if possible, and the 
sign-language' should be made an accessory. Some children do not 
acquire the former; so the latter must be employed. The admirable 
schools for the deaf in Chicago and other large cities go further and 
impart a useful education and more or less manual training in order 
to render their graduates self-supporting. 

M. A. Goldstein has published (The Laryngoscope, June, 189 T) 
the excellent results obtained bv the method of Urbantschitsch in 
persistent teaching of deaf-mutes by speaking vowel sounds, con- 
sonants, and their varying combinations into their ears until they 
are able to understand and repeat words and sentences. The author 
can recommend this method from practical experience with it. 




Fig. 230.— The London Horn. 



The education of the deaf should be no more neglected than that 
of the better favored of our race. Indeed, greater facilities should 
be afforded for the acquisition of an education and the acquirement 
of the prerequisites of good and useful citizenship, to counterbalance 
the unfortunate disadvantage at which they have been placed through 
no fault of their own. The means already enumerated are efficient. 
They are provided by private and public schools in the cities, and by 
the States in their deaf-and-dumb asylums. The formation of classes 
in the public schools of cities for the instruction of partially deaf 
children is advocated by H. A. Alderton (The Laryngoscope, August, 
1896). The subjects are usually intelligent and quick-witted, and 
their proper care and training will insure adequate returns upon the 
investment from both economic and humanitarian considerations. 



aids to hearing. 531 

Hearing-instruments. 

Of all the various devices for aiding the hearing two only have 
proven of actual practical value in my experience. They are the 
conical conversation-tube (Fig. 229) and the London horn (Fig. 230). 
The conversation-tube consists of a trumpet-shaped mouth-piece to 
collect the sound-waves, connected with an ear-piece — both being 
of hard rubber — by a conical, elastic, spiral-wire tube covered with 
rubber and woven silk. The mouth-piece is placed close to the lips 
of the speaker, when a low, conversational tone can be employed, 
enabling the listener to hear words that are inaudible to others. The 
speaker should never talk loudly or cough or clear his throat with 
the mouth-piece near his lips, for often the hypersensitiveness of the 
affected ear renders these harsh, explosive sounds painful and irri- 
tating. These tubes are generally worn about the neck, under the 
coat, or rolled up in the coat-pocket. For near conversation they 
are, by far, superior to any other device. 

The London horn (Fig. 230) is an excellent instrument for use 
at long distances, as in the church or lecture-room. It is made in 
three sizes and painted a dead-black preferably. The nickel-plated 
instruments are far more conspicuous. The horn is applied to the 
ear as in the case of the tube, and the large, open end is directed 
toward the source of sound. There is one serious objection to the 
metal horns : they convey a metallic, adventitious sound along with 
the principal sound. This defect is especially noticeable in listening 
to singing and the playing of an orchestra. However, it is preferred 
to the tube by many. The most distinguished of American news- 
paper editors was entirely dependent upon it, and could not be pre- 
vailed upon to try the tube. 

After an extensive destruction of the drumhead the hearing is 
sometimes much improved by placing a pledget of cotton lightly 
against the handle of the mallet. Sound-waves striking this are then 
communicated to the ossicles and so transmitted to the perceptive 
apparatus. In such cases the artificial ear-drum, consisting of a thin 
disc of soft rubber (Turnbull's) is inserted into the meatus and nicely 
adjusted to the exposed mallet. 

The audiphone, consisting of a fan-shaped disc of vulcanized 
rubber, bent by a silken cord into a convex surface to be presented 
toward the source of sound, the edge in contact with the upper teeth, 
has been used to some extent. The writer has tested it with numer- 
ous patients, but with few exceptions it was of little value. 



532 AIDS TO HEAKING. 

The rubber disc, apparitor auris, cornets, auricles, cones, etc., 
made of soft rubber and advertised extensively' in the newspapers, are 
generally of no use to patients, and are provocative of irritation, in- 
flammation, and even ulceration of the canal and tympanic membrane 
and cavity. Occasionally we have been told by the wearers that their 
hearing was better while these devices were in their ears. We have 
frequently found them in contact with the drumhead, bathed in de- 
composing pus. 

No efficient and harmless hearing-instrument for wearing in the 
ear has yet been devised. Fame and fortune await the inventor of 
the aural equivalent of spectacles. Alexander Graham Bell related 
to me that he discovered the useful principles of his telephone while 
endeavoring to invent a microphone to aid the deaf to hear. In 
response to my question, "Do you not consider it possible to con- 
struct an instrument for defective hearing that will be comparable 
to the lens for defective vision?" Mr. Bell replied, "I will not say 
that it is impossible; but, in the present state of our knowledge, it 
is improbable." 



CHAPTER XLV. 

LIFE-INSURANCE AFFECTED BY DISEASES OF THE EAR, NOSE, 

AND THROAT. 

There are certain diseases of the ear, nose, and throat that 
would unquestionably deter any competent examiner for life-insur- 
ance from accepting risks in which they were involved. Such dis- 
eases, for example, are lupus, carcinoma, cholesteatoma, and tuber- 
culosis. Tertiary syphilis, especially when the middle ear or the 
larynx is invaded, would be a valid cause for rejection of a candidate 
for life-insurance. This disease, on the one hand, may invade the 
labyrinth and even the more vital structures in the cranial cavity, or, 
on the other, its existence in the larynx threatens the deeper tissues, 
endangering life by strangulation from an exfoliated necrosed carti- 
lage or by a final stricture of the larynx. 

There are other diseases in respect to which there may be an 
honest difference of opinion as to their vitiating effect upon the ap- 
plication for insurance, and it is more particularly such as require a 
special knowledge and practical experience that we will consider. 

The external ear is occasionally the seat of pathological condi- 
tions that are apparently innocent in their incipiency, although they 
pursue a steady course to the development of a malignant disease with 
a fatal termination. A person may complain of nothing extraordinary 
relative to the ear beyond insignificant sensations of uneasiness and 
itching at some point which is slightly more prominent than the sur- 
rounding surface. Close examination may reveal a little thickening 
of the integument, possibly an abrasion produced by scratching. 
These points are easily overlooked by one who is not alert to the fact 
that lupus and carcinoma have their beginnings in such unsuspicious 
symptoms. Moreover, the patient's habit of scratching a given point 
and the resulting irritation may, according to Virchow, convert a 
benign neoplasm into a malignant growth. 

We may pass over the subject of acute inflammatory conditions, 
since no examiner would be expected to accept such risks. 

The effect of a chronic dry catarrhal inflammation of the middle 
ear on life-insurance is a question of considerable interest. Experi- 

(533) 



534 LIFE-INSUKANCE. 

ence has demonstrated that persons who are afflicted with such a dis- 
ease generally enjoy immunity from acute inflammatory attacks, and 
from suppurating processes in the middle ear. We very rarely ob- 
serve a case in which an acute inflammatory action or a suppurating 
process supervenes upon a chronic non-suppurative inflammation of 
long standing. But another important question relates to the possi- 
bility of life being shortened, not by the disease itself, but by accidents 
that are rendered more liable to occur by reason of the impaired hear- 
ing which the disease produces. Occasionally it happens that a person 
is run over by cars or other vehicles in consequence of an inability 
to hear their approach. There can be no sincere difference of opinion 
with respect to the greater liability to injury or death from such 
causes among those who suffer from a high degree of deafness; but 
many of this class are gifted with a compensating acuteness of vision 
and a quick, high order of intelligence which counterbalance their 
hearing-defect to a large extent. It is evident, then, that the ex- 
aminer should estimate, not only the amount of impaired hearing, 
but should also take into account the keenness of sight and the in- 
telligent alertness of the person. If he be dull mentally, slow to see, 
think, and act, he may be expected to become the easy victim of a 
careless driver or engineer; but if he possess an active muscular 
system well under the control of a vigorous mind, supplemented by 
normal vision, he may be relied upon as being quite capable of taking 
care of himself. 

Furthermore, a distinction must be made between the hyper- 
trophic or secretive form of inflammation of the middle ear, and the 
adhesive or sclerotic form. Although the former may be but a pre- 
cursor of the latter, in itself it is a much milder disease and is sus- 
ceptible of far more brilliant results from treatment. One may have 
the first, or milder, form for many years without suffering the ex- 
tinction of a large proportion of his hearing; but sclerosis causes a 
great loss of the hearing power. 

Chronic suppurative inflammation of the middle ear in an ap- 
plicant for life-insurarice, aside from the resulting deafness, is a 
subject that cannot be lightly passed over. Examiners appear to ex- 
ercise especial care in such cases. The author has observed repeatedly 
that life-insurance examiners have insisted that persons with dis- 
charging ears must have the suppuration cured before their applica- 
tions would be accepted. While writing this a patient lias just 
complied with an insurance examiner's requirement that he present a 



LIFE-INSUKANCE. 535 

statement from the author certifying that the suppuration of his mid- 
dle ear had been cured, notwithstanding the fact that it had ceased 
a year ago, and the ear had remained well ever since. 

In another instance an examiner refused to accept an applicant 
for life-insurance because he had a chronic suppuration of the middle 
ear, but stated that the application would be favorably acted upon if 
the ear were cured. Examination revealed granulations, necrosed 
ossicles, and carious tympanic walls, causing a foul discharge. The 
writer removed the granulations and ossicles and curetted the carious 
bone; a cure resulted and the patient secured his insurance policy. 
That the insurance examiners judgment was sound is evidenced by 
the fact that such cases tend strongly toward mastoid involvement, 
and that the patient still remains well after the lapse of six years. 
These instances are fair examples of the care and intelligence mani- 
fested by the medical examiners in protecting their companies against 
loss. 

On account of the vast possibilities of damage from suppuration 
of the middle ear it becomes a matter of the highest importance to 
the insurance companies, While the disease is easily curable if 
treated properly in its early stages, if neglected it not only jeopards 
the general health, but imperils life itself. The mucous membrane 
lining the tympanic cavity, which is the structure inflamed, serves 
the double purjDose of a mucous lining of this cavity and also of a peri- 
osteum. Therefore, it is so closely related to the bone that the latter 
is prone to become involved in the inflammatory process. The pneu- 
matic spaces of the mastoid process are lined by mucous membrane, 
which is a continuation of the membrane lining the middle ear; 
hence by continuity the inflammation extends from the tympanic 
attic through the aditus ad antrum into the mastoid antrum and cells. 
It is probable, in view of the relations of these cavities to each other, 
that whenever there is pus in the middle ear there is pus in the 
mastoid antrum also. 

Having in mind the conditions just described, it is not difficult to 
comprehend the far-reaching consequences of a suppurative inflam- 
mation of the middle ear and the mastoid process. The pus, break- 
ing through the confines of the softened bone upward through the 
roof of the tympanic cavity, reaches the middle cranial fossa, pro- 
ducing a subdural or cerebral abscess or meningitis; breaking forward 
it forms a retropharyngeal abscess, which may break suddenly into 
the pharynx and fill the larynx with pus, producing strangulation; 



536 LIFE-IXSTJRANCE. 

breaking downward it may burrow beneath the deeper layer of the 
muscles of the neck until it reaches the thoracic cavity; breaking 
backward from the mastoid cells, the pus empties into the posterior 
cranial fossa or into the lateral sinus. In the latter event pyaemia 
and phlebitis and thrombosis of . the sinus may result. Without 
prompt and skillful surgical interference the fatal character of these 
conditions is unquestionable. 

That it is well worth the while for medical examiners for life- 
insurance companies to attach sufficient importance to diseases of the 
ear is aptly illustrated by the experience of J. Morrison Ray (The 
Laryngoscope, August, 1897), who reported that out of 350 ear cases 
treated during the preceding year there were 6 fatal cases following 
suppuration of the middle ear. 

Diseases of the nose do not often prove fatal. Lupus, syphilis, 
and tuberculosis of this member are generally secondary to the oc- 
currence of these diseases in other locations. Carcinoma and sar- 
coma are rare in this part of the economy, and the examiner is not 
very likely to find causes here for the rejection of an applicant, un- 
less they are merely associated with the same causes in adajcent 
structures. However, one should be slow to accept an applicant who 
has a purulent discharge from his nose while such discharge con- 
tinues, since it might be the result of a purulent inflammation of the 
ethmoid cells or the frontal sinuses, which are in close relation to 
the meninges of the brain; or it might indicate empyaema of the 
maxillary antrum. Fibroma of the naso-pharynx would be a sufficient 
cause for rejection. 

If an applicant be subject to frequently recurring attacks of sore 
throat, especially every spring and fall, it should suggest rheumatic 
sore throat, and a possible rheumatic heart affection. The throat 
ought to be inspected for tubercular, syphilitic, or cancerous lesions; 
and one should not forget that the ravages of syphilis in the throat 
may reach an appalling extent without the patient complaining much 
of pain, and that the tonsils are sometimes the portal of entrance of 
tubercle bacilli into the system. 

The larynx is often the seat of tubercular manifestations, but 
these are so often secondary to pulmonary infection that they are 
quite likely to be suggested by an examination of the lungs. But one 
must not be thrown off his guard by this tad. for instances of primary 
laryngeal tuberculosis are not infrequent, and the larynx should be 
examined in every case in which hoarseness, difficulty of deglutition, 



LIFE-INSURANCE. 537 

and soreness in the region of the throat are found. The existence of 
tumefaction or ulceration in the larynx is sufficient cause for either 
rejecting the applicant or for holding his application without action 
until the abnormal condition is corrected or shown to be innocent 
beyond a reasonable doubt. A course of the iodides may demonstrate 
that the lesion is syphilitic and in a curable stage, or it may reveal a 
tubercular or carcinomatous incurable disease. Even in this test one 
may be easily deceived unless he remembers that carcinoma may im- 
prove temporarily under the iodides; but the improvement is transi- 
tory only, and is lost as the case progresses, while in syphilis the 
benefit remains and increases with a marked betterment of the gen- 
eral health. 

There is a common belief among those who are not well read in 
medical matters that the existence of a catarrhal condition of the 
upper respiratory tract is necessarily a forerunner of grave lung 
lesions. This fallacious notion is propagated with cunning zeal by the 
advertising medical charlatans for commercial reasons. The sug- 
gestiveness and plausibility of the idea render its exploitation an easy 
and profitable source of practice. They find the public mind ready 
to accept the belief that a catarrh of the nose and throat is almost 
certain to eventuate in consumption of the lungs. 

There is enough of the element of truth in such notions to be 
useful to the honorable practitioner, and to be susceptible of gross 
abuse at the hands of the mountebank. Certainly there is more like- 
lihood of a bronchitis or pneumonia occurring in a person of a pro- 
nounced catarrhal type than in one who "never takes cold." So, too, 
there is more liability of finding a rheumatic lesion of the heart in 
one who is subject to attacks of rheumatic laryngitis or pharyngitis. 
Indeed, there are subjects in whom a severe attack of pharyngitis or 
laryngitis almost invariably either terminates in bronchitis or evinces 
a very strong tendency to do so. A uric-acid diathesis should be 
looked for and corrected if found in applicants for life-insurance. 
Inquiries ought to be made with reference to their being subject to 
even slight onsets of rheumatism, neuralgia, migraine, sore throat, or 
symptoms of gout. The possibility of the development of angina 
pectoris should not be overlooked, since it is the result of uricacid- 
aemia; and, besides the aids already suggested as afforded by the con- 
dition of the upper respiratory tract, the examiner should be influ- 
enced by the evidence of hay fever and asthma, which are distinctly 
neuropathic diseases of a gouty origin. 



APPENDIX. 



REMEDIES. 



The composition of the remedies 
mentioned has been given according 
to the best information that could be 
obtained. 

Sprays. 

Lavolin: a liquefied vaselin with- 
out color, taste, odor, or irritating 
properties. 

Benzoinol: a product similar to 
lavolin, with the addition of benzoin. 

Camphor-menthol, pure: the liquid 
product resulting from bringing to- 
gether equal parts of camphor-gum 
and menthol crystals without heat 
(C 10 H 18 O). 

Micrazotol contains boroglycerid, 
eucalyptol, thymol, resorcin, menthol, 
and benzoic acid. (Acid reaction.) 

Listerin contains the essential anti- 
septic constituents of thyme, eucalyp- 
tus, baptisia, gaultheria, and mentha 
arvensis in combination. Each flui- 
drachm also contains two grains of re- 
fined and purified benzoboric acid. 

Pasteurin contains the active prin- 
ciples of cassia zelanicum {Lauracew), 
eucalyptus {Myrtacece), gaultheria 
{Ericacece), menthol combined with 
boroglycerid, and 0.3 per cent, of 
formaldehyde. (Acid reaction.) 

Formolid contains formaldehyd, ace- 
tanilid, boroglycerid, benzoborate of 
sodium, eucalyptol, thymol, menthol, 
oil of gaultheria, witch-hazel, and 
alcohol. (Acid reaction.) 

Borolyptol consists of 5 per cent. 
of acetoboroglycerid, 2 per cent, of 
formaldehyd, in combination with the 
active antiseptic constituent of pinus 
pumilio, eucalyptus, myrrh, storax, 
and benzoin. (Acid reaction.) 



Glycothymolin contains sodium, 
boric acid, benzoin, salicylic acid, 
eucalyptol, thymolin, menthol, and 
pine. (Alkaline reaction.) 

1^ Camphor-mentholis, 3 per cent. 
Lavolinis, 97 per cent. — M. 

B; Camphor-mentholis, 5 per cent. 
Lavolinis, 95 per cent. — M. 

B; Camphor-mentholis, 10 per cent. 
Lavolinis, 90 per cent. — M. 

B) Olei cubebse, 4 per cent. 

Benzoinolis, 96 per cent. — M. 

B> Camphor-mentholis, 10 per cent. 
Olei cubebse, 90 per cent. — M. 

B, Eucalyptolis, 3 per cent. 
Olei picis liquidae, 3 per cent. 
Lavolinis, 94 per cent. — M. 

— M. R. Brown. 



B) Salolis, 4 per cent. 
Mentholis, 4 per cent. 
Lavolinis, 92 per cent. 



-M. 



B Olei eucalypti, 1 per cent. 
Thymolis, 1 per cent. 
Mentholis, 3 per cent. 
Olei gaultherise, 1 per cent. 
Lavolinis, 94 per cent. — M. 

B Olei cubebae., £ss. 

Camphor-mentholis, 3ss. 
Olei eucalvpti, 3 s s. 
Olei gaultheriae, 31 j. 
Lavolinis, Siij- 
(Use the pure camphor-menthol.) 



B Thymolis, gr. x. 

Eucalyptolis, gr. xx. 
Mentholis, gr. xxx. 
Olei cubebse, gr. xl. 
BenzoinoliSj %\v. 
Olei rossej q. s. — M. 

— O. B. Douglas. 
(539) 



540 



APPENDIX — REMEDIES. 



IJ Eucalyptolis, 4 per cent. 
Benzoinolis, 96 per cent. — M. 

R; Mentholis, 3 per cent. 

Lavolinis, 97 per cent. — M. 

IJ Olei pini sylvestris, 4 per cent. 
Benzoinolis, 96 per cent. — M. 

IJ Iodini, 

Acidi carbolici, of each, gr. ij. 
Benzoinolis, 3j. — M. 

IJ Olei pini sylvestris, min. xxx, 
Olei eucalypti, 3j. 
Olei gaultheriae, min. xxx. 
Camphor-mentholis, 3j. 
Terebinthinae Canadensis, 3j. 
Tincturae benzoini, q. s. ad 0iv. — M. 

IJ Iodini, gr. xx. 

Acidi carbolici, gr. xij. 
Camphor-mentholis, 3j. 
Lavolinis, q. s. ad §iv. — M. 

IJ Calendulae, 4 per cent. 
Hamamelidis, 8 per cent. 
Pini strobi, 8 per cent. 
Lavolinis, 80 per cent. — M. 

Infusion of the flowers of calendula 
and the leaves of hamamelis with lav- 
olin. 

IJ Salolis, 3 per cent. 

Olei gaultheriae, 4 per cent. 
Thymolis, 3 per cent. 
Benzoinolis, 90 per cent. — M. 

IJ Aristolis, 10 per cent. 
Mentholis, 3 per cent. 
Benzoinolis, 87 per cent. — M. 

IJ Aristolis, 5 per cent. 
Mentholis, 8 per cent. 
Benzoinolis, 87 per cent. — M. 

IJ Creasoti, 4 per cent. 

Acidi carbolici, 3 per cent. 
Olei picis liquidse, 3 per cent. 
Olei gaultherise, 4 per cent. 
Benzoinolis, 86 per cent. — M. 

IJ Acidi borici, 

Sodii bicarbonatis, 

Sodii chloridi, of each, 3ij. 

Glycerini, 3iij. 

Aquae rosae, %iv. 

Aquae, q. s. ad Oj. 

M. Filter. 



IJ Iodoformi, gr. ij. 
Benzoinolis, 3j. — M. 

IJ Camphor-mentholis, 3 per cent. 
Olei pini sylvestris, 2 per cent. 
Eucalyptolis, 1 per cent. 
Benzoinolis, 94 per cent. — M. 

IJ Sodii chloridi, 3j. 

Sodii phosphatis, gr. ij. 

Sodii sulphatis, gr. xij. 

Potassii sulphatis,. gr. ij. 

Potassii chloridi, 

Potassii phosphatis, of each, gr. iij. 

Mentholis, gr. j. 

Glycerini, 3iij. 

Aquae, q. s. ad Oj. — M. 

IJ Acidi tannici, gr. xl. 
Acidi gallici, gr. xx. 
Sodii bicarbonatis, 3ss. 
Aquae, Oj.— M. . 

— Sajous. 

IJ Sodii chloridi, 
Sodii bicarbonatis, 
Sodii biboratis, of each, 3j. 
Aquae, Oj. — M. 

IJ Sodii biboratis, 

Sodii bicarbonatis, of each, 3ij. 
Acidi carbolici, gr. xlviij. 
Glycerini, 3iiiss. 
Aquae, q. s. ad Oj. — M. 
(DobelPs solution.) 

IJ Sodii biboratis, 

Sodii bicarbonatis, of each, §j. 
Sodii benzoatis, 

Sodii salicylatis, of each, gr. xx. 
Eucalyptolis, 
Thymolis. of each, gr. x. 
Mentholis, gr. v. 
Olei gaultheriae, gtt. vj. 
Glycerini, ^viiiss. 
Alcoholis, 3ij- 
Aquae, q. s. ad Oxvj. — M. 
(Seller's solution.) 

IJ Acidi carbolici, gr. xx. 
Sodii boratis, 

Sodii bicarbonatis, of each, 3j. 
Glycerini, 

Aquae rosae, of each, 3j- 
Aquae, q. s. ad Oj. — M. 

— Leffert. 

IJ Antinosinae, gr. v. 
Aqua\ 3j-— M. 



APPENDIX REMEDIES. 



541 



IJ Zinci sulphatis, gr. xv. 
Thymolis, gr. 1 / 3 . 
Alcoholis, 

Glycerini, of each, §iss. 
Aquae menthas piperitas, §x. — M. 

P* Pulveris aluminis, gr. v-xxx. 
Aquas, §j. — M. 

— J. Solis-Cohen. 

P* Antipyrinas, gr. xv. 
Aquas, Sj. — M. 

Py Aristolis, 5-10 per cent. 
iEtheris, 95-90 per cent. 
M. Signa: Spray for tuberculous 
ulcers. 

P* Morphias sulphatis, gr. iv. 

Acidi tannici, 

Acidi carbolici, of each, gr. xxx. 

Aquse destillatas, of each, §ss. 
M. Signa: Spray for tubercular 
ulcers. 

P* Sodii boratis, gr. v. 
Aquas rosas, 3j- — M. 



Steam-inhalations. 
Infusion of opium, 3i-Oj. 
Infusion of belladonna, 3i-Oj. 
Infusion of hyoscyamus, 3i-Oj. 
Infusion of conium, 3i-Oj. 

Compound tincture of benzoin, a 
teaspoonful to the pint of hot water. 

Pure camphor-menthol, gtt. x to the 
pint. 

Glycerinum acidum carbolicum, a 
teaspoonful to the pint. 

P* Glycerini, §j. 
Aquas calcis, 3iij. 
M. Signa: Use in a steam-atom- 
izer. 

P* Acidi carbolici, 

Zinci sulphocarbolatis, of each, 3j. 

Glycerini, §j. 

Aquas, q. s. ad §iv. 
M. Signa: Use in a steam-atom- 
izer. 



Antiseptic and Astringent 
Solutions, etc. 

P* Acidi borici, gr. xx. 
Aquas rosas, §j. — M. 
(For the ear.) 

P* Acidi borici, gr. x. 

Aquas destillatas, 3j- — M. 
(For the eye.) 

P* Zinci sulphatis, gr. ij. 
Acidi borici, gr. x. 
Aquas destillatas, §j.— M. 
(For the eye.) 

IJ Zinci sulphatis, 

Acidi carbolici, of each, gr. viij. 
Glycerini, 3j. 
Aquas, §ij. — M. 

(Ear-lotion.) 

IJ Acidi borici, gr. xx. 
Alcoholis, l\. — M. 

(For the ear when granulations are 
present.) 

IJ Sodii bicarbonatis, gr. xx. 
Glycerini, 3ij. 
Aquas, 3vj. 

M. Signa: Use (warm) in the ear 
to soften cerumen. 

IJ Acidi borici, gr. xv. 
Aquas rosas, Bj- — M. 

IJ Hydrargyri bichloridi, gr. j. 
Aquas cinnamomi, %x. 
M. Filter. 

P* Hydrargyri chloridi corrosivi, 3j< 

Acidi tartarici, 3v. 

Aquas, q. s. ad §iv. 
M. Signa: Ounce ss ad Oj aquas 
(1 to 1000). 

IJ Hydrargyri chloridi corrosivi, 
Sodii chloridi., of each, 3j. 
Aquas, q. s. ad §j. 

M. Signa: Drachm j ad Oj aquas 
(1 to 1000). 

P* Hydrargyri chloridi corrosivi, 3j. 

Ammonii chloridi, gr. xxxij. 

Aquas, q. s. ad §j. 
M. Signa : Drachm j ad Oj aquae 
(1 to 1000). 



542 



APPEXDIX REMEDIES. 



F* Iodoformi, 20 per cent. 
Alcoholis, 80 per cent. — M. 

F* Hydrargyri bichloridi, q. s. ad 1- 
5000 in aquam. 

F£ Acidi carbolici, 3vj. 
Aquae, q. s. ad Oj. — M. 

P* Acidi carbolici, 3j. 
Olei olivae, 3x. 
M. Signa: Carbolized oil. 

Hydrozone: a 30- volume dioxide 
(peroxide) of hydrogen; iL0 2 . 

Glycozone, a chemically pure, anhy- 
drous glycerin saturated with ozone- 
gas at 0° C. ; powerful non-toxic, 
non-irritating germicide. 

p£ Creolinis, Sj. 

Signa: Drachm i-vj ad Oj aquae. — 
Esmarch. 

F* Acidi borici, 3iv. 
Aquae destillatae, Oj. 
M. Signa: Saturated solution. 

F* Acidi salicylici, 3ss. 
Boracis, gr. xx. 
Aquae, Oj. — M. 
(For ozaena.) 

P*, Aluminis, 3j. 

Acidi carbolici, gr. viij. 
Glycerini, §j. 
Aquae destillatae, §vij. 
M. Filter. 

P* Potassii chloratis, 3j. 
Extract! hamamelidis, 3j. 
Aquae destillatae, §v. 
M. Filter. 

P* Tincturae ferri chloridi, 
Glycerini, of each, 3j. 
Aquae destillatae, §vj. 
M. Filter. 

P* Sodii bicarbonatis, 1 per cent. 
Aquae, 99 per cent. 
M. Signa: Use for boiling instru- 
ments (to prevent corrosion). 



IJ Potassii chloratis, 3j. 
Aquse cinnamomi, Sviij. 

M. Filter. 



P* Potassii permanganatis, 3ij. 
Aquae, Oj. — M. 

P* Acidi carbolici, 5 per cent. 
Aquae, 95 per cent. 
M. Solution for disinfecting instru- 
ments. 



Gargles. 



P* Boracis, 3ij. 

Acidi carbolici, gr. xvj. 

Glycerini, 3ij. 

Aquae rosae, q. s. ad §viij. — M. 

P* Aluminis exsicc, 3j. 
Aquae rosae, Sviij. — M. 

P* Aluminis, 

Potassii bromidi, of each, 4 per 

cent. 
Aquae, 92 per cent. 
M. Signa : Gargle. 

P*. Potassii chloratis, 3iv. 

Or 

P* Potassii bromidi, 3iv. 

Dissolve in a pint of pure water and 
gargle. 

P* Boracis, 

Potassii chloratis, of each, 3i '. 
Potassii carbonatis, 3vj. 
Sodii chloridi, §ij- 
Aquae, q. s. ad Oj. — M. 



Solutions for Injecting into the 
Middle Ear Through the Eu- 
stachian Tube. 

Pilocarpine hydrochlorate, 2-per- 
cent, solution. 

Six or 8 drops to be injected 
through the Eustachian catheter. 

P* Sodii bicarbonatis, gr. x. 
Aquae, 3j. — M. 

Ifc Potassii iodidi, gr. v. 
Aquae. 3j. — M. 

P* Camphor-mentholis, 3 per cent. 
Lavolinis, 97 per cent. — M, 



APPENDIX REMEDIES. 



543 



Pigments. 

Saturated solution of suprarenal 
gland. 

I£ Acidi tannici, gr. x-xxx. 
Acidi salicylici, gr. v. 
Glycerini, 3ij. 
Aquae destillatae, 3vj. — M. 

I£ Aluminis, gr. x. 
Glycerini, 3ij. 
Aquae destillatae, 3vj. — M. 

IJ Zinci sulphatis, gr. v. 
Glycerini, 3ij. 
Aquae destillatae, 3vj. — M. 

IJ Zinci chloridi, gr. x-1. 
Glycerini, 
Aquae destillatse, of each, 3iv. — M. 

I£ Cupri sulphatis, gr. x. 
Glycerini, 3ij. 
Aquae destillatae, 3vj. — M. 

I£ Iodoformi, 3j. 
Collodii, 3x.— M. 
(Iodoform-collodion.) 

■ — Kttstek. 

I£ Iodoformi, 3j. 
^Etheris, Bj ; — M. 
(Iodoform-ether.) 

IJ Iodoformi, gT. xxx. 

yEtheris, §ss. 

Aquae destillatae, q. s. ad §j. — M. 

(Iodoform-ether.) 

— Nussbaum. 

I£ Glycerini acidi carbolici, 3ij. 
Glycerini acidi tannici, 5ij- — M. 

IJ Acidi carbolici, 12 per cent. 
Glycerini, 88 per cent. — M. 

Glycerinum acidum tannicum. 

3 Olei eucalypti, 

Acidi carbolici, of each, %]. 
Terebinthinae, §viij. — M. 

Jfc Guaiacolis, 

Glycerini, of each, 3ss.— M. 

I£ Morphiae sulphatis, gr. iv. 
Acidi carbolici, gr. xxx. 
Glycerini, §j. — M. 



Ifc Morphiae sulphatis, gr. iv. 
Acidi carbolici, 

Acidi tannici, of each, gr. xxx. 
Glycerini, 3j. — M. 

Ifc Argenti nitratis, gr. xl. 
Aquae, 3j- — M. 

IJ Argenti nitratis, gr. x. 
Aquae, 3j.— M. 

I£ Creasoti, 2 per cent. 
Mentholis, 10 per cent. 
Lavolinis, 88 per cent. 

M. Signa: Apply to tubercular 
ulcers. 

Lactic acid, applied to tubercular 
ulcers. At first it should be used in 
a solution of 20 to 40 per cent., gradu- 
ally increasing to 100 per cent. 

IJ Creasoti, gr. x. 

Mentholis, 3j. 

Lavolinis, §j. 
M. Signa: Apply to tuberculous 
ulcers. 

Tincture of iodine. 

I£ Plumbi acetatis, gr. v. 
Aquae, §j. 
M. Signa: For syphilitic throat. 

I£ Zinci chloridi, gr. xx. 
Aquae, Bj. 

M. Signa: For syphilitic throat. 

I£ Cupri sulphatis, gr. xv. 
Aquae, §j. 
M. Signa : For syphilitic throat. 

Pyoktanin. 

Sulphocalcin, either diluted or full 
strength, for dissolving false mem- 
branes. 

I£ Potassii permanganatis, gr. xxx. 

Aquae, gj. — M. 

(Antiseptic, and solvent of false 
membranes.) 

I£ Acidi carbolici, gtt. xx. 

Liquoris ferri subsulphatis, 3iij. 
Glycerini, §j. 

Aquae destillatae, 3ij- — M. 
(Local application for diphtheria.) 



544 



APPENDIX REMEDIES. 



Lactic acid, applied locally by in- 
halation or by a cotton swab. (A 
solvent of false membranes.) 

IJ Alcoholis, 60 per cent. 
Toluolis, 36 per cent. 
Liquoris ferri chloridi, 4 per cent. 
— M. 

(Loffler's formula for the local treat- 
ment of diphtheria. On account of 
the pain this solution produced, 
Loffler added to this 20 per cent, of 
menthol.) 



Counter-irritants and Liniments. 

Cantharidal collodion. 

Essential oil of mustard. 

Tincture of iodine. 

IJ Linimenti saponis, 

Linimenti camphoris compositi, of 
each, 3j. — M. 

1$, Linimenti belladonna?, 

Linimenti opii, of each, 3iv. — M. 

T£ Linimenti chloroformi, 
Linimenti aconiti, 
Linimenti belladonnas, 
Linimenti opii, of each, 3iv. 
Linimenti saponis, Sj. — M. 

IJ Tincturae Valerianae, 3ij. 
iEtheris sulphurici, 3j. 
Glycerini, 3xij. — M. 

IJ Olei tiglii, 

Chloroformi, of each, 3ij. 
Aquas ammonii fortioris, §j. 
Olei sesami, §iij. 
M. Signa: Apply on cotton. 



I I£ Unguenti zinci oxidi benzoinati, 

I£ Hydrargyri oxidi flavi, gr. v. 

Unguenti petrolei purificati, §j. — 
M. 

]$ Unguenti acidi carbolici, §j. 

I£ Unguenti acidi carbolici, §ss. 

Unguenti zinci oxidi benzoinati, 
giss— M. 

I£ Acidi salicylici, gr. xv. 
Petrolati, §j. — M. 

Epidermol. 

Resinol. 



Ointments. 

Vaselin, petrolatum, or petroleum 
ointment: the purified residue after 
distilling off the lighter and more 
volatile portions from American pe- 
troleum. 



Caustics. 



1$, Acidi chromici, 

Aquae, of each, 3j. — M. 

Chromic acid fused into a bead 
(page 457). 

Silver nitrate fused on a probe. 

Glacial acetic acid. 

Nitric acid. 

Monochloracetic acid. 

London paste. 

Trichloracetic acid. 

Electrocautery. 



Powders. 



Aristol. 
Nosophen. 
Iodoform. 
13oric acid. 



APPENDIX EEMEDIES. 



545 



IJ Bismuthi carbonatis, gr. ij. 
Morphiae, gr. 1 / 2 - 7 6 . 

(For insufflation.) 

IJ Sodii bicarbonatis, 
Sodii boratis, 
Amyli, of each, gr. iss. 
Cocainae hydrochloratis, gr. x. 
Sacchari lactis, q. s. ad gr. c. — M. 

IJ Morphiae hydrochloratis, gr. ij. 

Bismuthi subnitratis, 3vj. 

Pulveris acaciae, 3ij. 
M. Signa: 'Terrier's snuff," for 
cold in the head. 



Tablets. 



IJ Ammonii chloridi, gr. j. 

Tincturae opii camphoratae, 

Syrupi scillse compositi, 

Syrupi Tolutani, of each, min. v. 

Extracti glycyrrhizae, gr. iij. 
M. Signa: Throat-, or cough-, tab- 
let. 

IJ Morphiae sulphatis, gr. V 12 . 
Atropiae sulphatis, gr. V 600 . 
Caffeinae, gr. 1 / 6 . 
M. Signa : Coryza-tablet. 



Local, Anaesthetics. 

Cocaine. 

Eucaine. 

IJ Acidi carbolici, 12 per cent. 
Glycerini, 88 per cent. — M. 



Genekal Anaesthetics. 
Ether. 
Chloroform. 
Ethyl-bromide: hydrobromic ether. 



Gexeeal Remedies. 

Sodium bromide in doses of 30 or 
60 grains in large amount of water, 
especially at bedtime. 

IJ Zinci valerianatis, gr. ij. 

Extracti nucis vomicae, gr. 1 / i . 
Extracti gentianae, gr. ij. 

M. Fiat pilula. 

Signa: One pill thrice daily. 

IJ Ammonii chloridi, 3j. 

Tincturae opii camphoratae, 

Syrupi scillae compositi, 

Syrupi Tolutani, 

Syrupi glycyrrhizae, of each, §j. 
M. Signa: Teaspoonful every two 
or four hours. (Cough-syrup.) 

IJ Calcii sulphidi, gr. iij. 

Fiat in pilulas No. xij. 
Signa : One three times a day for 
suppuration. 

Acidi arseniosi, gr. 1 / 30 thrice daily 
for furunculosis and herpes. 

IJ Tincturae ferri chloridi, 3ij. 
Glycerini, §j. 
Aquae, §iij. — M. 

IJ Ferri reducti, 

Quiniae sulphatis, of each, gr. j. 
Strychniae sulphatis, gr. y 60 . 

M. Fiat in pilulam No. j. 
This pill may be taken two or three 
times a day, after meals. 

IJ Tincturae ferri chloridi, 3j. 
Glycerini, 
Aquae, of each, §j. — M. 

(Billington's formula.) 

IJ Hydrargyri chloridi mitis, 

Sodii bicarbonatis, of each, gr. j. 
— M. 

IJ Hydrargyri chloridi corrosivi, gr. 

/lOO" /o0' 

Sacchari albi, gr. iii-v. 

M. Triturate; fiat in chartulam 
No. j. 

Signa: Apply dry on the tongue 
every hour. (For diphtheria or 
croup.) 



35 



546 



APPENDIX — REMEDIES. 



Remedies for Tinnitus Aurium. 

R> Acidi hydrobromici diluti, 3j. 
Aquae, §iij. 

M. Signa: A teaspoonful well di- 
luted three times a day. 

Fluid extract of cimicifuga race- 
mosa, in 30-drop doses daily. 



Febrifuges. 
Antipyrin. 
Phenacetin. 
Acetanilid. 



Sedatives. 



Exalgin. 



Potassium bromide. 



1$, Bromidise, §ij. 

Signa : One - half teaspoonful in 
water every half-hour until pain is 
relieved. 

Aconite. 

R> Tincturos aconiti, 3ss. 

Potassii bromidi, 3iss. 

Aquae, §ij. 
M. Signa: Teaspoonful every hour 
in tonsillitis. 



Emetics. 

Apomorphine. 

Hydrargyri subsulphas flavus (tur- 
peth mineral). 

Powdered alum. 

Ipecac. 

Sulphate of copper. 



Remedies for Rheumatic and 
Gouty Affections. 

Salicin. 

Salicylic acid. 

Salol. 

3 Acidi salicylici. 3iij. 
Sodii bicarbonatis, 3ij. 
Elixiris gaultherise, §ss. 
Glycerini, 3iij. 
Aquae, q. s. ad %iv. — M. 

Lithium carbonate or citrate. 

Alkalithia. 

Citrate of lithia, soda, and potash 
(effervescent). 

Sodium phosphate (alkaline laxa- 
tive and cholagogue). 



Remedies for Tuberculosis. 

Codliver-oil and maltine. 

B> Vini ferri citratis, %iv. 

Signa : Dessertspoonful after each 
meal. 

P* Syrupi hvpophosphitis compositi 
* (Fellows's), Oj. 
Signa : A teaspoonful three times a 
day after meals. 

P* Olei morrhuae, Oj. 

Signa: A teaspoonful thrice daily, 
after meals, in lemon-juice or coffee; 
or inunction twice daily, rubbing a 
tablespoonful into the skin of the ab- 
domen, and covering with oiled silk 
or flannel. 

Guaiacol in doses of 1 to 10 minims 
after each meal, given in glycerin, 
milk-broths, or wine. 

Creasote, 1 to 10 minims or more 
three times a day. given in milk, alco- 
holic or tonic preparations, or in cap- 
BUl< 



APPENDIX KEMEDIES. 



547 



Remedies for Syphilis. 

B Hydrargyri bichloridi, gr. j. 
Potassii iodidi, §ss. 
Syrupi sarsaparillae, §iv. — M. 

I£ Syrupi ferri iodidi, 3iv. 

Glycerini, £iss. 

Aquae, §iv. 
M. Signa: Teaspoonful three times 
a day. 

B Sodii iodidi, §ss. 

Essentiae pepsinae (Fairchild), 
Syrupi zingiberis, of each, §iij. 
M. Signa: Drachm j ter die. 

Pilocarpine-hydrochlorate solution, 
2 per cent. Ten or 15 drops to be in- 
jected under the skin. (For labyrin- 
thal disease, syphilitic.) 

IJ Potassii iodidi, gr. viij. 

Ferri et ammonii citratis, gr. xxiv. 

Elixiris aurantii, 

Aquae, of each, 3ij. 
M. Signa : Drachm j or ij thrice 
daily. (For children.) 



I£ Potassii iodidi, 3iv. 
Ammonii carbonatis, 3j. 
Elixiris simplicis, §j. 
Infusionis calumbae, §v. 

M. Signa: Tablespoonful in water 
three times daily. (For syphilis and 
caries.) 

I£ Potassii iodidi, 3j. 

Ferri et ammonii citratis. 3ij. 
Infusionis calumbae, q. s. ad §vj. 

M. Signa: Tablespoonful in water 
thrice daily. 



Miscellaneous. 

Nitrite of amyl; used for inhala- 
tion in hay fever, asthma, and col- 
lapse from anaesthetics. Dose, 10 or 
20 drops. 

Pure camphor-menthol inhaled from 
a bottle or glass tube, for hay fever 
and cold in the head. 



INDEX. 



Abbott, 171 

Abel, 73 

Abscess, cerebral and cerebellar, 474 

extradural, 473 

metastatic, 474 

of brain, 474 

of larynx, 290, 291 

of neck, 241, 512 

of nose, 97 

retropharyngeal, 240, Plate IV 

subdural, 473 

tonsillar, 198, 201 
Accessory cavities of the nose, dis- 
eases of, 104 
Accidents in operations, 143, 231 
Acoumeter, 350 
Acute otitis externa, 387 
.Acute otitis media, 402 

appearances of membrana tvmpani, 
403, Plate VIII 

grip as a cause, 19, 20 

leech, artificial, 405 

leeches, 405 

naso-pharynx, 128, 134, 136 

paracentesis membranae tvmpani, 
406 

relief of pain, 404 

treatment, 404 
Acute purulent otitis media, 407 

grip as a cause, 19, 20 

influenza as a cause, 19, 20 

membrana tvmpani. appearance of, 
408, 4i0, 411, Plate VIII 

micro-organisms, 407 

treatment, 408 
Acute rhinitis, 21 

Adenoid hypertrophy of vault of 
pharynx, 134 

ear complications. 134, 136 

eye complications, 119 
Adjustable light, 2, 3, 340 
Age, influence of, in diseases, 162, 331 
Agnew, 515 
Air, compressed, and apparatus, 356- 

370 
Air-pressure, 357 
Alderton, H. A., 530 
Alkaline spravs. Appendix 
Alt, 121 



Amaurosis, 69, 121 

Amberg, E., 497 

Amblyopia from nasal disease, 121, 

122 
Amygdalitis, 19S 
Anaemia of the labyrinth, 514 
Anaesthesia, bromide of ethyl, 137-143 

local, in nasal surgery, 66 

of pharynx, 243 
Anaesthetics, general, 439 
Andrews, A. H., 9, 497 
Angina catarrhalis acuta, 147 

Ludwig's, 204 

rheumatic, 154, 156 

scarlatinous, 160 

tonsillaris, 198 
Angioma of pharynx, 238 
Ankylosis of the ossicles, 419 
Anomalies of auricle, 380-383 

of external meatus auditorius, 382, 
383 

of pharynx, 229 

of sensation in larynx, 297 

of uvula, 217 
Anosmia. 92 

Antiseptic sprays. Appendix 
Antrum, aditus ad, Figs. 220, 221 

irrigator, 109 

mastoid, Figs. 220, 221 

maxillary, 104 

of Hiohmore, 104, 109 
Aphonia, 299 
Applicator, caustic, 458 
Aquaeductus Fallopii, Figs. 209, 210, 

220, 221 
Arnold, J. D., 265 

Arrangement of instruments and ap- 
paratus, Fig. 1 
Arslan, 134, 527 
Artificial drumheads, 461 
Asch, Morris J., 95 
Aspergillus of the ear, 390 
Aspirator for the ear, 454 
Asthenopia from nasal disease, 81, 

118, 120, 121, 122 
Asthma. 29, 30. 31. 35. 37, 39. 41. 44. 
45. 82. 95, 121 

from nasal disease. 31. 39. 51, 59 
Astigmatism from nasal disease, 121 

(549) 



550 



INDEX. 



Asymmetry of nasal bones, 57, 93 
Atmospheric causes of disease, 18, 19, 
24, 34, 42, 43, 46, 120, 129, 
147, 205, 203, 208, 284, 293, 
334, 391, 520 
Atomizers, 8, 9, 10 

Atresia of external auditory meatus, 
392 

nasal, 101 
Atrophic catarrh of naso-pharynx. 130 

rhinitis, 73 
Audiphone, 531 
Auditory canal, 384 

acute inflammation, 387 

boils of, 388 

bony growths, 392 

cerumen, 384 

chronic inflammation, 387 

exostoses, 392 

foreign bodies, 393 

furuncles 388 

hyperostosis, 392 

imperforate, 392 

malignant disease, 370, 378 

narrowing, 392 

neoplastic closure, 302 

parasitic inflammation, 390 

sequestra, 408, 471 
Auditory nerve, 518-523 
Aural fungi, 390 

vertigo, 385, 388, 400 
Auricle, benign tumors of, 379 

carcinoma, 378 

cutaneous diseases, 375 

cystoma, 379 

deformities, 380-383 

eczema, 375 

frost-bite, 375 

gangrene, 377 

hematoma, 379 

herpes, 380 

hypertrophy, 380 

inflammatory affections, 375-380 

intertrigo, 380 

lupus, 376 

malignant disease, 378 

othamiatoma, 37'.) 

pemphigus, 380 

perichondritis. 378 

scroll-deformity, 382 

syphilis. 380 

wounds and injuries, .'is.', 
Auscultation-tube and method of 

using, 373, 37 1 
Autoaspiral ion. 41 7 
Autoinllat ion of the middle ear, 360, 

416, 430 
Automatic tuning-fork, 'H7 
Autophony, 385, 402 
Autoscopy, 257 



Bacon, G., 396 
Bag, ice-, 483 
Baginsky, 170 
Baker, A. R., 485 

Baldness not a cause of disease, 335 
Ballinger, W. L., 23 
Bandage, net, 500 
Barclay, Robert, 443 
Barr, Thomas, 390 
Bartlev, 36 
Baum, W. L., 196 
Baurowiez, 73 
Bean, C. E., 202 
Behvens, B. M,, 438 
Behring, 187, 188 
Bell. A. G., 532 
Berens, B., 27 
Bergmann. 474 
Bertillon, 38 
Bezold. 407, 402 
Bifid uvula, 217 
Bing's hearing-test, 350 
Bisehoff, 30!) 
Bishop, D. D., 190 
Bishop, S. S., 123 
Black, G. XL, 71 

Biake, Clarence J., 437, 443, 444 
Bleeding, local, in acute otitis media, 405 
Blennorrhoea. 24 
Blepharitis, 118, 119 
Blepharospasm, 121 
Blindness from sphenoid disease, 112 
Blitz catarrh, 17 
Boils in the external ear, 38S 
Bone, turbinated, inferior, Plates I, II, 
III, IV 
middle, Plates I, II, III. IV 
superior, Plates I. IL, 111, IV 
Bone-conduction, 346, 348 

in chronic aural catarrh. 422 
Bostock, John, 30 

Bosworth, Francke 11., 5, do, 284, 320 
Bouchard, 3(5 
Bouchut, 273 
Bougies, Eustachian, 401 

nasal, 26 
Boxing the ears. 370. 396 
Bracket, adjustable lamp-. 340 
Brain-abscess, 474 
Braun, 75 

Breathing, mouth-. 58, 135, 2S4 
Brennecke, II. A.. L96 
Bresgen, lis. 120 
Broadbent, 39 
Bromide of ethyl. 137-143 
Brown, Dillon. 272' 
Brown, J. Trice-. 96, 213, 307 
Brown, Moreau K.. 55 
Browne, J. Lennox. 152, 1S2. 201. 220 
2ss. 306, 315, 320, 324, 325 



INDEX. 



551 



Brovvn-Sequard, on haematoma, 379 
-Bryant, W. S., 449 
Buck, A. H., 369, 394, 518 
Burnett, Charles H., 49, 391, 437, 443 
Burns and scalds of the pharynx, 245 

Caisson, effect on ear, 39(3 

Calcareous degeneration of the middle 

ear, 418, 419, Plate VIII 
Calculi, nasal, 82 

tonsillar, 215 
Camphor-menthol, 13 

inhaler, 15 
Canal, external auditory, 384 

Fallopian, Figs. 170, 220, 221 

glands of external meatus, Fig. 170 

imperforate, 392 

section of, Fig. 170 
Canalis tensoris tympani, 399 
Cancer of pharynx, 235 
Carcinoma, of ear, 378 

larynx, 320 

nose, 85 

pharynx, 235 
Caries and necrosis from middle-ear 

diseases, 449, 457, 467 
Carious teeth, 104, 214 
Carotid artery, rupture of, in suppura- 
tion of middle ear, 469 

canal, 499, 500 
Cary, Frank, 278 
Case-records, 352-355 
Casselberry, William E., 54, 80 
Catarrh, chronic, of middle ear, 412, 
418 

exudative, 412 

heredity of, 420 

hypertrophic, of the nose, 57 

nasal, 21 

nervous, 29 

of the middle ear, sero-mucous, 412 

purulent, 24 
Catarrhal fever, 17 

otitis media, acute, 402 
Catheter, Eustachian, 372 

in chronic aural catarrh, 416, 429, 
430 

method of using, 369 
Causes of disease, atmospheric, 18, 19, 
24, 34, 42, 43, 46, 126, 129, 
147, 205, 263, 268, 284, 293, 
334, 391, 520 
Caustic applicator, 458 

chemical, 457 

for nose and throat, 60 
Cauterization, electric, 67, 68 
Cautery, electric, 60-68 
Cavities, accessory, of nose, 104 
Cerebellar abscess, 474 
Cerebral abscess, 474 



Cerebral causes of deafness, 523 
Cerebro-spinal rhinorrhcea, 27 
Cerumen, impacted and inspissated, 

384 
Chapman, J., 55 
Charcot, 522 

Cheatham, William, 55, 123 
Chiari, 75, 323, 325 
Cholesteatoma of mastoid, 462 
of middle ear, 462 
of tonsils, 214, 215 
Stacke's operation 504 
Chondromata, nasal, 81 
Chorda tympani nerve, 435, Fig. 165 
Chorditis tuberosa, 292 
Chorea of pharynx, 244 
Chrobak. 72 

Chronic catarrh of the middle ear, 412, 
418 

adhesive inflammation, 418 

age, 420 

alcohol, effects of, 420, 421 

ankylosis of ossicles, 419 

atrophic stage, 418 

auditory hallucinations, 520 

autoaspiration in, 416, 417 

autophony, 415 

calcareous degeneration, 418, 419 

climatic conditions, 415, 421, 520 

deafness, 422 

differential diagnosis, 415, 423 

electricity, 432 

Eustachian catheter, 372, 417, 429, 
430 
tube, 59, 399, Plate I 

excision of membrana tympani 
and ossicula, 437, 439 

exudation, 412 

foreshortening- of handle of mal- 
let, 413, Plate VIII 

frequency of, 332, 333 

heredity, 420 

hygienic surroundings, 334 

hyperemia, 412 

hypertrophic, 412 

injection of liquids, 429 
vapors, 429 

loud noises, effects of, 421, 422 

mobilization of stirrup, 443 

ossicles in, 419 

otalgia, 414. 421 

pain in ear, 414 

paracentesis, 406 

paracusis, 423 

partial excision of membrana 
tympani, 436 

peculiar modifications of hearing, 
414, 415 

pneumatic tests, 414 

proliferation, 418 






552 



INDEX. 



Chronic catarrh of the middle ear, re- 
moval of membrana tympani 
and ossicles, 437, 439 
stapes, 440, 442, 444 

retraction of membrana tympani, 
413, Plate VIII 

sclerosis, 418 

secretive, 412 

sensations of discomfort, 414, 415 

statistics, 331-336 

tenotomy of tensor tympani, 437 

tinnitus aurium, 415, 421, 519 

tobacco, effects, 420 

uric acid, 419 

vertigo, 415, 422 
purulent otitis media, 445 

antiseptic powders, 451 
solutions, 450, Appendix 

appearances of membrana tym- 
pani, 445, Plate VIII 

caries and necrosis of adjacent 
tissues, 449, 457, 467 
of ossicles, 446, 459 

caries of carotid canal, 469 

cause of intracranial lesions, 450, 
469 

cerebral abscess from, 450, 469 

cholesteatoma, 462 

deafness following suppuration,461 

excision of drumhead and ossi- 
cles, 443 

exfoliation of cochlea, 467 

facial paresis and paralysis, 463 

granulations, 448, 456 

labyrinthal invasion, 449 

mastoid complications, 448, 450 

meningitis, 450, 472 

metastasis, 474 

paralysis and paresis, facial, 463 

perforation of the membrana flac- 
cida, 446 

perforations of the drumhead, 460 

phlebitis of lateral sinus and jug- 
ular vein, 450, 469, 477 

polypi, 449, 456 

pyseinia, 450, 469 

rupture of carotid artery, 469 

seat of intracranial lesions, 450 

sequelae, 456-47'.' 

sequestra, 468, 471 

symptoms, 448 

of brain-abscess, 474 
of sinus-tbrombosis. 477 

thrombosis of lateral sinus and 
jugular veins, 450, 477 

treatment, 450 
suppurative tympanitis, 44."> 
Chronicity of diseases. 335 
Circumscribed otitis externa, 388 
Cirrhotic i limit is, 73 



Clark, Sir Andrew, 56 
Classification of disea-ses, 331-336 

of occupation, sex, etc., 331-336 
Cleft palate, 218, 383 
Clergyman's sore throat, 161 
Climatic influences, 18, 19, 24, 34, 42, 
43, 46, 126, 129, 147, 205, 266, 
268, 284, 293, 334, 391, 520 
Cline, L. C, 106 
Clinical records. 352-355 
Clothing, 24, 130, 272 
Coakley, C. G., 95, 213 
Cocaine, 26, 231 
Cocamization, 66, 231 
Cochlea, 470 

exfoliation, 467 
Cohen, J. Solis-, 55, 163, 222, 288 
Cold, catching, 22, 147, 261, 268 
Cold in the head, 21 
Coleman, W. F., 118 
Colles, C. G., 419 
Comparison of statistics, 336 
Compressed air, 356-374 

apparatus, 356-370 

meters, 357, 364, 369, 370, Fig. 1 
Concretions of drumhead, 418, Plate 
VIII 

tonsils, 215 
Congenital deafness, 526 

deformities of nose, 101 
Conjunctivitis from nasal disease, 117, 

118, 119, 120 
Conklin, 37 
Coppez, 120 
Coroin, 272 

Corneal inflammation from nasal dis- 
ease, 120 
Coryza, 21 

tablets, 21 
Cotton, A. C, 196 
Cotton-carriers, 288, 289, 343 
Cough-tablets, 151 
Coulter, J. H., 409 
Cozzolino, 444 
Croup. 267 

intubation, 273 

laryngismus stridulus, 296 

membranous, idiopathic, 267 

spasm of the glottis, 296 

spasmodic. 296 

spurious, 261 

tracheotomy, 27!' 

choice of operation, 280 

treatment, 271 
Cruveilhier, 238 

Crypts of tonsils, ins. -nu. 215 
Curettes, 188 
Curtis. 11. II.. 52, 55 
( ui oil. compressed air, 358 
Cutter, Ephraim, 318 



IXDEX. 



553 



Cystoma of auricle, 
larynx, 313 
pharynx, 235 



379 



Dabney, Samuel C, 119 
Dacryocystitis from nasal disease, 118. 

120 
Dalby, W. B., 393 
Daly, W. H., 55 
Darwin, 42 
Davey, James R., 469 
Davis, Nathan Smith, 37, 50 
De Lamalleree, 56 
De Schweinitz, 117 
De Yilbiss, Alien, 251 
Deaf-mutism, 134, 526 
Deafness, causes of, 400, 403, 415, 421, 
448, 515, 516, 517, 518, 522, 
523, 524, 525, 526 

congenital, 526 

following suppuration of middle ear, 
461 

hereditary, 527 

hysterical, 522 
Deflections of septum nasi, 93 
Deformities of auricle, 380 383 

nose, 93, 101 
Delavan, D. B., 99, 141, 214 
Delstanche, Charles. 417, 428, 451 
Dench, Edward B., 464 
Desire, 307 
D*Espine. 170 
Dieffenbach, 133 
Diet, 50, 130, 152 
Dilatation of pharynx, 232 
Dilators for nose, 26 
Dionisio, 75 
Diphtheria, 167 

age of patients, 170 

bacillus, 167, 168 

diagnosis, 175 

diphtheric exudate, 167 

diphtheroid, 174, 175 

effect on ear, 174, 176 
eye, 120, 174 

false, 167, 169 

incubative period, 171 

intubation, 273 

microbe, 167, 168, 175 

of the nose and naso-pharynx, 174, 
176, 184 

paralysis, 174, 185 

propagation, 172 

prophylaxis, 178, 188 

pseudodiphtheria, 167, 169 

sequels, 185 

symptoms, 172 

treatment, 177 
antitoxin, 187 
hygienic, 178, 179, 180 



Diphtheria, treatment, internal. 185 

local, 181 

serum-therapy, 187 

tracheotomy. 279 

vital it v of Klebs-Eoffler bacillus, 
170 
Diphtheroid, 174, 175 
Direct laryngoscopy, 257 
Disinfection, 66, 136.. 177-180 
Diverticulum. 232 
Dobell's solution. 16 
Dodd, Oscar, 112 
Double hearing, 519 
retractors, 490 
uvula. 217 
Douche, nasal, 9 
Douglas, O. B., 94 

Drumhead. See Membrana tympani. 
Ducts emptying into nasal meatuses, 

11L 117. 119 
Duel, A. B., 401 
Dunbar, 52 
Dunn, J., 119 
Dynamomotor, 65 
Dysphonia, 313 

Ear disease, brain-abscess, 474 

from diphtheria, 174, 176 

from disorders of nervous svstem, 
518, 523 

from exanthemata, 159, 160 

from grip, 19, 20 

from influenza. 19, 20 

from intracranial growths. 524 

from leucocythaemia. 517 

from meningitis, 523 

from nasal disease. 59. 128 

from pharvngeal disease, 128, 136, 
14S,"l52. 163. 236 

from syphilis. 517 

from tonsillitis. 199 
Ear, electrodes, 432, Eig. 188 

internal , 514 

malformations, 380. 3S2 

middle, 390, Figs. 220, 221 

noises, subjective, 385. 391, 398, 400, 
403 

relation of nose to, 398 

specula, 341 
Ear-cough, 385 
Ear- fungi, or mold, 390 
Ebstein, 37 

Ecchondrosis. nasal cavities, 81 
Eczema of auricle, 375 

eyelid and face. 118 
Ehrlich, 187 

Electric-current transformer. 65, 06 
Electric motor. 65 
Electric trephines. 70 
Electricity in various diseases, 60, 93, 432 



554 



INDEX. 



Electrode, laryngeal, 321 
Electrodes, ear-, 432, Eig. 188 

nasal, 64, 67 
Emphysema from inflation of nose, 

116 
Empyema of antrum of Highmore, 104 
of frontal sinuses, 112 
of maxillary sinuses, 104 
Enslee, Charles L., 331 
Epidemic catarrh, 17 
Epiglottis retractor, 255 
Epiphora from nasal disease, 118 
Epistaxis, 76 

plugging nares, 77 
Epithelioma of ear, 378 
of larynx, 320 
of nose, 85 
of pharynx, 235 
Epizootic, 17 

Erectile tumors of nasal cavities, 80 
Ethmoid sinuses, diseases of, 109 
osteoma, 110 
polypi, 109, 110 
Etiology of diseases, 331-337 
Eustachian catheter, 372, 417, 429, 430 
emphysema from use cf, 373, 374 
method of using, 369 
salpingitis, 398 
tube, 59, 399, Plate I 

canalis tensoris tympani, 399 
cartilage of, 399 
constriction of, 398 
fossa of Rosenmiiller, 372 
isthmus, 399 
membranous part, 399 
orifice, 372, 399 
patency, 398 
stenosis, 398, 401 
Euthanasia, 324 

Examination of patients, 3, 251, 338 
Exanthemata, effect on ear, 335 
effect on nose, 21 

effect on pharynx, 159, 160, 161, 240 
Excision of membrana tympani and 
ossicula, 437, 439 
partial, of membrana tympani, 436 
Exophthalmic goitre, 121 
Exostoses of auditory canal, 392 

of nasal cavities, 70, 81 
External ear, 375 

auricle, 375 
Ex1 1 adural abscess, 473 
Exudative catarrh of middle car, 412 

sore throat, 161 
Eye (li-r;i>cs from diseases of the nose, 

ll(i 
Eyestrain, 12:5 

Facial expression in diseases <>t' the 
nose and throat, 135, 137 



Facial paralysis, 463 

Faith, Thomas, 374 

Fallopian canal, Figs. 170, 220, 221 

False diphtheria, 167, 169, 174, 175 

hearing, 519 
Farcy, 90 

Fatality of chronic suppuration of the 
middle ear, 445, 468, 469, 472, 
474, 477, 482, 483 
Fenestra ovalis, Fig. 218 

rotunda, Figs. 174, 175 
Fenger, Christian, 27 
Fessler, 138 
Fetid catarrh, 73 
Fibroma of larynx, 313 

of nasal cavities, 79, 131 

of pharynx, 238 
Fick, 147 
Fischer, 120 
Fliess, 72 

Floor of the tympanum, Fig. 170 
Folds of membrana tympani, Fig. 118 
Follicular pharyngitis, 161 
Foreign bodies in ear, 393 

in larynx, 326 

in nose, 101 

in pharynx, 245 
Fork, automatic tuning-, 347 
Fossa of Rosenmiiller, Fig. 136, Plate 

VIII 
Fournier, 225 
Fourth tonsil, 212 
Fracture of base of skull, 525 

of nose, 100 
Frankel, 318 
Frankenbersf, 134, 527 
French, J. M., 100 

Frequency of disease, relative, 332-336 
Frontal sinuses, diseases of, 112, 115 

transillumination, 114 
Frost-bite of auricle, 375 
Fruitnight, 272 
Fungi, aural, 390 
Funk, 120 
Furuncles of ear, 388 

of nose, 91 

Galezowski, 123 

Galton's whistle. 350 

Galvanocautery, 60. 67, 68 

Ganglion, sphenopalatine, 31 

Gangrene of the ear. :>77 

Garcia, -260 

Garlick, 11. S., 143 

(idle. 444 

Gellfi's hearing-test, 350 

General considerations, 331 

Generative organs and the voice, 300 

i renital spots of nose. 72 

< rersuny, 101 






IXDEX. 



555 



Glanders, 90 

Glasgow, W. C, 54, 222, 271 

Glaucoma, 120, 121 

Gleason, 96, 443, 454 

Gleitsmann, J. W., 94 

Glenoid fossa, Fig. 211 

Globus hystericus, 213, 244, 247, 298 

Glottis, spasm of, 290 

Gluck, I., 56 

Goldstein, M. A , 103, 467, 530 

Gonorrhoea, nasal, eye symptoms, 120 

Gottstein, 139, 271 

Gouges, 487 

Gouguenheim, 56, 202 

Gould, G. M., 118 

Gout, a cause of hay fever, 36, 48 

effect on the ear, 419 
nose, 23 
Gouty sore throat, 154, 156 
Grant, J. Dundas, 271. 315, 429 
Granular pharyngitis, 161 
Granulations in suppuration of the 
middle ear. 448, 456 

of vocal cords, 292 
Grav, L. C, 40 
Greene, J. O., 437 
Grip, 17 

cause of otitis media, 19, 20 

effect on ear, 19, 20 
Gruber, Josef, 356, 516 
Gruhn, 118 
Guenod, 120 
Gummata of larynx, 324 

of pharynx, 223 
Gunn, Moses, 107 
Guttmann, 120, 185 
Guye, 522 

Habermann, J., 419, 462 

Hack, 121 

Hematoma of auricle, 379 

of nose, 97 
Haemorrhage from adenoid operation, 
140, 141 

from varicose veins, 213 

nasal, 76 

of internal ear, 516 

operative, 232 

pharyngeal, 239 
Haig, Alexander, 36-39 
Hajek, 73, 323 
Hall, Marshal], 296 
Hallucinations, auditory, 520 
Hamilton, T. K., 119 
Hanau, 204 
Hansell, 121 

Hardie, T. Melville, 55, 142 
Hartman, A., 360 
Hartmann's inflation experiments, 360 

tuning-forks, 347, 348 



Hasse, 237 
Hay asthma. 29 
Hay fever, 29 

antitoxin, 52 

etiology, 34, 42 

gout, 36, 48 

medical opinions, 53 

nasal disease in, 31, 33 

neurosis, 29 

organic disease, 30, 31, 33, 34, 51 

pathology, 29 

symptomatology, 44 

treatment, 46 

uric acid, 36 
Head-minor, 339 
Hearing, double and false, 519 

instruments, 531 

tests of, 346-353 
Heitzman, 36 
Hektoen, Ludwig, 27 
Henoch, 170 

Hereditary deafness, 420, 527 
Heredity, '41, 42, 87, 88, 148, 218, 305, 

321, 527 
Herpes of auricle, 380 • 
Herpetic pharyngitis, 164 
Heryng, 114, 221, 320 
Hiahmore, antrum of. 104 
Holmes, C. R., 143 
Hooks, double mastoid, 490 
Hooper, 141 
Horsley, 475 
Hotz, F. C, 402, 454 
Hubbard, Thomas, 237 
Hutchinson, 517 
Hydrorrhoea, 25, 27, 44 
Hyperemia of the labyrinth, 514 
Hyperesthesia acoustica, 519 
Hyperesthesia of larynx, 297 

of nose, 32, 34, 35 

of pharynx, 242 
Hyperaudition, 518 
Hyperostosis in auditory canal, 392 
Hyperplasia, nasal cavities, 57 
Hypertrophic sore throat. 161 
Hypertrophies, nasal cavities, 57 

posterior, surgery of, 136 

tonsillar, 204 
Hypertrophy of auricle, 3S0 

of tonsils^ 204 
Hysterical deafness, 522 

aphonia, 299, 302 

Icebag, 4S3 

Illumination, 3, 4, 251, 339 
Imperforate external meatus, 392 
Incision of membrana tympani, 400 

over mastoid process. 485 
Incus, Figs. 165, 170, 189, 220, 221 

articulation, Figs. 165, 170, l!)2 



556 



INDEX. 



Inflation of tympana, 3G8-373 

Politzer s method, 3G8 

Valsalva's method, 3G0, 416, 430 
Inflators, 370, 371 
Influence of age on diseases, 162, 331 

of occupation, 331 

of sex, 331 
Influenza, 17 

cause of otitis media, 19, 20 

effect on ear, 19, 20 
Ingals, E. Fletcher, 165, 221 
Inhalents, 12-16 
Inhalers, 15 
Instruments, ear, 338-351 

hearing-, 531 

mastoid, 486-490 

nasal, 4-12 
Insufflators, Figs. 83, 144, 178 
Insurance, life-, 533 
Internal ear, 514 

anaemia, 514 

aural vertigo, 385, 388, 400, 415, 422, 
449, 467, 473, 474, 514, 515, 
516, 517, 524, 525 

concussion of labyrinth, 525 

fracture at base of skull, 525 

haemorrhage, 516 

hypersemia, 514 

hypersestiiesia acoustica, 519 

hysterical deafness, 522 

leucocythaemic deafness, 517 

Meniere's disease, 516 

new growths, 524 

panotitis, 515 

primary acute labyrinthitis, 514 

suppurative exfoliation, 467 

syphilis, 517 
Intertrigo of auricle, 380 
Intubation of larynx, 273 
Iritis from nasal disease, 120, 121 
Irrigator, antrum, 109 

Jack, Frederick L., 437, 443, 476 
Jackson, 517 
Jackson, A. Reeves. 40 
Jarvis, 69, 315 
Jewell, J. S., 47 
Joal, 42 
Jones, 455 
Jones, Bence, 47 
Jugular fossa, Figs. 170, 213 
vein, phlebitis of, 450, 477 
t hrombosis of, 477 

Kayser, 213 

Keratitis from n;i sa 1 disease, IIS. 120 

Kin near. B. 0., 55 

KLirstein, A.. 257 

ECitasato, 187, 189 

Kitchen, iyo, 202 



Klebs, Edwin Theodore, 167, 190, 191 

Knapp, H., 120, 476, 523 

Knife in septum deformities, 70 

Knight, C. H., 54, 75, 140 

Knight, F. I., 292 

Koch, 189, 307 

Kocher, 133 

Konig, 133 

Korner, 475 

Kossel, 189 

Kramer, 527 

Krause, 221, 325 

Kriickmann, 204 

Kuh, Edwin J., 55 

Kiister, 476 

Labyrinth, concussion, 525 

diseases of, 514 

injuries', 525 
j Labyrinthitis, primary acute, 514 
j Lacrymal canal, affection of, from 
nasal disease, 1 17, 118, 120 
Lacrvmation from nasal disease, 117, 

118, 120, 121, 123 
Lacunae of tonsils, 198, 214 
Laker, 75 
Lange, 50 
Langenbeck, 133 
Langerhans, 190, 191 
Laryngeal forceps, 315, 319 

paralysis, 301 

spasm, 296 
Laryngismus stridulus, 270, 291, 296 
Laryngitis, acute, 261 
symptoms, 262 
treatment. 264 

atrophic, 290 

catarrhal, 261 

chronic, 283 
treatment, 288 

cedematous, 2(53, 292 

phlegmonous, 290 

purulent. 290. 292 

rheumatic, 266 

simple, 2(51 

spasmodic, 263 

stridulous, 203 

suppurative, 290 

syphilitic, 308 

tubercular, 304 
Laryngoscope. 251 
Laryngoscopie image, Plate TV 
Laryngoscopy, difficulties of, 254 

direct. 257 

indirect. 25] 
Larynx, abscess .of, 290 

acute catarrh of. 261 

anatomy of, Plate V 

anomalies of sensation, 297 

cancer. 320 



INDEX. 



557 



Larynx, chronic catarrh of, 283 
deformities, 310 
examination, 251-260 
foreign bodies in, 326 
treatment, 326 
laryngotomy, 318 
tracheotomy, 279 
growths in, 312, 320 
carcinomata, 320 
chondrosarcoma, 326 
cystomata, 313 
epitheliomata, 320 
fibromata, 313 
mucous polypi, 313 
myxomata, 313 
pachydermia, 318 
papillomata, 312 
polypi, 313 
sarcomata, 325 
singer's nodule, 319 
haemorrhages, 310 
intubation of, 273 
neuroses of, 296 
aphonia, 299 
hyperesthesia, 297 
neuralgia, 297 
paresthesia, 297 
paralysis, 301 
spasm of glottis, 296 
cedema of, 263, 292, 326 
stenosis, 293. 305, 308, 310, 311 
syphilis, 308 
tuberculosis, 304 
tumors, 312 
vocal bands, Plate IV 
Lateral sinus, Figs. 190, 193, 209, 212, 
213, 214, 222 
phlebitis of, 450, 469, 477 
thrombosis of, 477 
Laurens, 121 
Lavolin, 13 

Lederman, M. D., 479, 485 
Leeches, 405 
Lees, D. B., 56 
Lefferts, 326 
Leflaive, 37 
Leiters coil, 202 
Leland, G. A.. 414 
Leonard, C. H., 300 
Leukaemia, effect on ear, 517 
Lever, 36 

Levy, Robert, 69, 213, 222 
Life-insurance, 533 
Light for examination, 3, 251, 339 
Light-condenser, 339 
Lincoln, R. P., 161 
Linea temporalis, Fig. 211 
Lingual tonsil, 212 
Linhart, C. P., 27 
Loewenberg, 73, 336 



Loftier, 167, 184 
Love, I. X., 185 
Lucse, 428, 462 
Luchvig's angina, 204 
Lupus of the ear, 376 

of the nose, 90 
Luschka, tonsil of, 134 
Lymphangioma, 238 
Lymphosarcoma of pharynx, 239 

MacCoy, Alexander W., 241 
Macewen, 475 

Mackenzie, John Xoland, 55 
Mackenzie. Sir Morell, 206, 228, 267, 

300, 324 
Maggots in the nose, 103 
Malformations of the ear, 380, 382 
Malignant disease from suppuration 

of the middle ear, 376, 378 
Malignant neoplasms in larynx, 320 
in the nasal cavities, 84. 85 
in the naso-pharynx, 134 
Malleus, Figs. 147, 165, 170, 189, 220, 
221 
fracture of, 433 
ligaments, Fig. 147 
Marckwort, 124 
Marcy"s law, 38 
Martin, 187 

Massage otoscope, 342, 426 
of external meatus, 431 
of nose, 74 

treatment of ear, 343, 426, 427 
vibratory, 74 
Mastoid antrum, Figs. 220, 221 
cells, Figs. 220, 221 
curettes, 488 

disease in otitis media, 479 
guide, 489 
hooks, 490 
inflammation, 479 
cholesteatoma, 462 
complications of, 479 
instruments for operation, 486- 

491 
operative treatment, 485, 486 
primary, 479 
sclerosis, 481 
operations, 492-512 

haemorrhage in, 490, 493, 496 
portion, temporal bone, Figs. 220, 
221 
Maxillary antrum or sinus, 104 
Mayer, E., 96 
Mays, Thomas J., 37 
McBride, P., 56, 455 
Measles, sore throat, 159 
Meatus, external auditory, 384 

internal auditory, Figs. 193, 20S, 
219 



558 



INDEX. 



Membrana flaccida, Fig. 118. Plate VIII 
Membrana tympani, 344, 345, Plate 
VIII 

atrophy of, 413, 418 

chorda tympani, 435, Fig. 165 

excision of, 437, 439 

folds, Fig. 118 

granulations, 448, 45G 

haemorrhage, 390 

hyperemia, 390 

inflammation, 390 

adhesions, 419, 423, 459, 401 

injuries, 396 

inspection, 344 

massage of, 343, 420 

membrana flaccida, Fig. 118 
propria, Fig. 118 

normal, 344, 345 

paracentesis of. 406 

perforations, 400 

pockets, or pouches, Fig. 147 

polypi, 449, 45(5 

position of ruptures, 440 

Prussak's fibres, 345 
space, Fig. 147 

resection of, 437 

retraction of, 413, Plate VIII 

rupture of, 300, 390, 402, 525 

shape, 344, 345 

Shrapnell's membrane, 345 

thickening of, 414, 418 

topographical relations, 345 

topography of outer surface, 345 
of inner surface, Fig. 165 

umbo, Plate VIII 
Membranous sore throat, non-diph- 
theric, 104 
Mendoza, Suarez de, 428 
Meniere's disease. 510 
Meningitis, 450, 472 

effect on ear, 523. 520 
Metastasis in suppuration of the mid- 
dle ear, 474 
Meter, air-. 357, 304. 309, 370, Fig. 1 
Michael's inflation experiments, 302 
Middle ear, 396, Figs. 220, 221 

chronic catarrh of, 412, 418 

gouty and rheumatic diathesis, 419 

instruments. Figs. 107, 1S1 
Migraine, 36, .'>7. 50 
Milbury, F. S., 473 
Miles, 123 
"Mind cures," 299 
Miner, forehead-, 339 

-holder. 339 

throat . 5 
Mittendorf, W. F., 117 
Mobilization of the ossicles. 4:53 
Mobilizal ion of I he s1 irrup, 1 13 
Monod, 189 



Moos, 479, 510, 523 
Mouth-breathing, 58, 135. 284 
Mulhall, 284 
Murehison, 30 
Mutes, deaf-, 134, 520 
Mycomyringitis, 390 
Mycosis of "ear. 390 

of pharynx, 214 
Mygind, 527 
Myles, R. C , 202 
Myringitis, 390 

parasitica, 390 
Myxomata of larynx, 313 

nasal, 79 

Narcosis, bromide-of-ethyl, 137-143 
Nares, posterior, plugging in epi- 

staxis, 77 
Nasal abscess, 97 
acute catarrh, 21 
atrophic catarrh, 73 
atresia, 101 
carcinomata, 85 
cavities, abscess of septum nasi, 97 

anosmia. 92 

blood-tumors, 97 

bony occlusion, 81 

calculi, 82 

cancer, 85 

carcinoma, 85 

chondromata. 81 

cold in head, 21 

cystic polypi, 79 

deformities, 93, 101 

deviation of the septum, 93 

diphtheria, 174 

ecchondrosis. 81 

erectile tumors, 80 

exostosis. 81 

eve diseases from nasal affections, 
lit) 

fibrous polypi, 79 

foreign bodies, 101 

fractures, 100 

furuncles, 91 

glanders, 90 

haemorrhage, 7(> 

hyperplasias, 57 

hypertrophies, 57 

lupus, 90 

maggots, 103 

malignant neoplasms, 84, 85 

mucous polypi, 79 

occlusion, 101 

osteomata, 8] 

papillomata, 80 

parosmia. !K> 

perforations of septum, 95, 98 
polypi, 79 
reflexes, 121 






INDEX. 



559 



Nasal cavities,, rhinoliths, 82 
sarcomata, 84 
sense of smell. 92, 93 
supporter for nose, 89 
synechias, 57, 81 
syphilis, 87 
tuberculosis, 86 
disease in hay fever, 31, 33 
diseases from eye affections, 116, 

117, 118 
douche, 9 

cause of inflammation of the mid- 
dle ear, 9 
duct, 117, 119 
haemorrhage, 76 
myxoma. 79 
polypi, 79 

reflex neuroses, 29, 121 
septum, 93. 97 
speculum, 4 
stenosis, 22, 44 
supporter, 89 
Naso-pharyngeal diphtheria, 174, 176, 

184 
Nasopharynx, 126 

climate, effect of, 126 
Eustachian tube, 59, Plate I 
fossa of Rosenmiiller, Fig. 136, 

Plate I 
tonsil of Luschka, 134, Plate I 
diseases of, in otitis media, 398 
adenoid growths in, 134 
atrophic catarrh, 73 
diphtheria, 174 
examination, 3 
facial expression, 135 
follicular catarrh, 126 
polypi, fibromucous, 133 

fibrous, 131 
tumors, 131 
voice, 128 
Nebulizers, 10, 11, 12 
Neck-abscess, 241, 512 
Necrosis of adjacent structures in 
middle-ear disease, 449, 457, 
467 
NeisAvanger, C. S., 62 
Neoplasms of larynx, 312, 320 
of nose, benign, 79 
malignant, 84. 85 
Nerve, auditory, 518 

facial, 463, Figs. 209, 210, 214, 218, 

220, 221 
olfactory, 92, 93 
Nervous catarrh, 29 

coryza, 29 
Net bandage, 500 
Neuralgia of larynx, 297 
of pharynx, 243 
supra-orbital, 112 



Neuroses, nasal reflex, 29, 121 
of ear, 518 
of larynx. 296 

of nose, asthmatic, 29, 30, 31, 32, 
35, 37. 39. 41, 44, 45, 51 
eye disease, 121 
hyperesthesia, 32, 34, 35 
migraine, 36, 37, 50 
reflexes in the eye, 121 
respiratory, 29 
treatment, 46, 124 
of olfaction, 92, 93 
anosmia, 92 
parosmia, 93 
of pharynx, 242 
Neurotic character of hay fever, 29 
Nevius light, the, 486 
Newcomb, J. E., 140, 141 
Newman, 325 
Nieden, 120 

Noises in the ear. See Tinnitus aurium 
North, John, 56, 75, 165, 181 
Northrup, 267, 277 
Nose, 3 

diseases of, abscess of septum, 97 
accessory sinuses, 104 
affecting the eye, 116 
animate foreign bodies in, 103 
anosmia, 92 
asthma, 29, 30, 31, 32, 35, 37, 39, 

41, 44, 45, 51 
carcinoma. 85 
deformities, 93, 101 
diphtheria, 174 
epistaxis, 76 
examination, 3 
'foreign bodies, 101 
furunculosis, 91 
glanders, 90 
hamiatoma, 97 
lupus, 90 
maggots, 103 
nose-bleeding, 76 
ocular symptoms, 116 
ozama, 73 
parosmia, 93 
polypi, 79 
rhinitis, acute, 21 

chronic, hypertrophic, 57 
simple, 24 
rhinoliths, 82 
sarcomata. 84 
septal perforations, 95, 98 
sexual relations. 72 
sprays. S. !>, 10 

supporter for bridge and tip, 89 
syphilis, 87 
tuberculosis. 86 
ducts. Figs. 65, 67, 68 
examination and instruments, 3 






5G0 



INDEX. 



Nose, fractures, 100 

hsematoma, 97 

pathological conditions affecting the 
eye, 11(3 

relation to the ear, 398 
Nose-bleeding, 70 
Noyes, H. D., 122 



Occlusion of nasal cavities, 101 
Occupations, influence of, 331 

classified, 331 
O'Dwyer, Joseph, 270, 273 
QCdema of eyelids from nasal disease, 
121 
glottidis, 292 
of larynx, 292, 320 
of pharynx, 100 
of uvula, 210 
Ohmann-Dumesnil, A. H., 217 
Olfaction, neuroses of, 92, 93 
Olfactory nerve, 92, 93 
Oilier, 133 

Operations, asepsis in, 00 
Ophthalmia, gonorrheal, from nose, 

120 
Optic nerve, compression of, from 
ethmoid disease, 121 
sphenoid disease, 112 
Orbital cellulitis, 120 
Ossicles, auditory, Figs. 105, 170, 189, 
192, 220, 221 
articulation, Figs. 105, 170, 192, 220, 

221 
caries of, 440, 459 
chronic aural catarrh, 412, 418 
excision of, 437, 439 
hook, 440 
incudo-stapedial articulation, Figs. 

170, 192, 221 
vibrator, 433 
Osteomata, nasal cavities, 81 
Othematoma of auricle, 379 
Otitis externa acuta, 387 
chronica, 387 
circumscripta, 388 
diffusa, 387 
parasitica, 390 
media acuta, 402 

from nasal douche, 402 
paracentesis, 400 
chronica, 412, 418 
purulenta acuta, 407 
chronica, 445 
Otomycosis, 390 
Otorrhea, chronic, 445 
Otoscope, massage, 342 
Overtreatment, 432 
Ozena, 73 

cause of eye diseases, 120 



Pachvdermia laryngis, 318 
Palate, Plates I, III, IV 

cleft, 218 

perforation, 229 
Panas, 119 
Panophthalmitis, 120 
Panotitis, 515 
Papillomata of larynx, 312 

of nasal cavities, 80 

pharynx, 234 
Paquin, Paul, 307 

Paracentesis membrane tympani, 400 
Paracusis duplicata, 519 

Willisii, 519 
Paresthesia of larynx, 297 

pharynx, 243 
Paraffin injections, 101 
Paralysis of auditory nerve, 522 

facial nerve, 403 

from diphtheria, 174 

larynx, 301 

pharynx, 244 
Parasitic otitis externa, 390 
Paresis of auditory nerve, 522 

facial nerve, 403 
Park, Roswell, 325 
Parke, 30 
Parosmia, 93 
Patton, J. Allen, 36 
Pemphigus of auricle, 380 
Perforation of membrana tympani, 
400 

of nasal septum, 95, 98 
Perichondritis of auricle, 378 
Periosteum separator, 490 
Pfeiffer, R, 18 
Pharyngeal tonsil, 134 
Pharyngitis, acute, 147 
effect on ear, 148 
treatment, 149 

chronic, 153 

follicular, 101 

following nasal cauterization, G9 

herpetica, 104 

in measles, 150 

membranous, simple, 104 

parasitic, 214 

rheumatic, 154, 150 

scarlatina, 100 

smal -pox, 101 

syphilitic, 222 

tubercular, 219 
Pharyngomycosis, 214 
Pharynx. 147. Plates I. Ill, IV 

acute inflammation, 147. 150 

anomalies and new growths, 229 

burns and scalds, 245 

deformities, 229 

dilatation. 229, 232 

diphtheria, 107 



IXDEX. 



5G1 



Pharynx, diverticulum, 232 
effects of nasal disease on, 162 
foreign bodies, 245 
globus hystericus, 247 
herpes, 164 
malformations, 229 
malignant disease. 235, 239 
morbid growths, 229, 234 
angioma, 238 
cystoma. 235 
fibroma, 131, 238 
innocent growths, 234 
lipoma. 238 
lymphangioma, 238 
papilloma, 234 
malignant growths, cancer, 235 
carcinoma, 235 
epithelioma, 236, 237 
lymphosarcoma, 239 
sarcoma, 239 
mycosis, 214 
neuroses, 242 
of motion, 243 
of sensation. 242 
new growths, 229 
paralysis, 244 
parasitic disease, 214 
rheumatism, 154, 156 
spasms, 243 

stenosis, 225, 227, 229, 230, 232, 240 
syphilis, 222 
tuberculosis, 219 
uvula, bifid and double, 217 
inflammation, 216 
malformations, 217 
Phlebitis of sinuses, 450, 477 
Phlegmonous inflammation of antrum 
of Highmore, 109 
of tonsils, 202 
Phlyctenular disease from rhinitis, 

118, 119 
Phonograph, 430 
Photophobia from nasal disease, 120, 

121, 123 
Politzer, Adam, 360, 361, 419, 516, 523 
Politzerization, 368 
Pollen as a cause of hav fever, 33, 42. 

52 
Polypi, aural, 449, 456 
cystic, nasal, 79 
mucous, of larynx, 313 
nasal, 79 

naso-pharynx, 133 
Pomeroy, O. D., 437 
Porcher, W. P., 299 
Porter, 268 
Post-nasal catarrh, 126 

vegetations, 134 
Powder-blowers, Figs. 83, 144, 178 
Powders, see Appendix 



Preparation of patients and instru- 
ments for operations. 487, 
488 

Prognosis in ear diseases. 333 

Prophylaxis of acute rhinitis. 24 

Prudden, 167 

Piussak's space, Fig. 147 

Pseudodiphtheria, 167, 169 

Pseudomembranous croup, 267 

Psvchic influence in hav fever. 30 

Puech, 120 

Pulling the ears, 379, 396 

PumpSj air-, 366-368 

Purdy, C. W., 36 

Purulent otitis media, acute. 407 
chronic, 445 

pyaemia in, 450, 469 

Pyle, E. W., 485 

Pynchon, Edwin, 4, 84, 212 

Quain, 48 
Quinlan, 69 
Quinquaud, 37 
Quinsy, 198 

Ramsey, 119 

Randall, 336, 379 

Ranke, 270 

Ray, J. M., 536 

Records of cases, 352-355 

Reflex affections of the eye and nose, 

121 
nose, 29, 31, 59, 81, 82, 95, 121 
voice, 300 
Reflexes, laryngeal, 300 
nasal, 121 
ocular, 121 
sexual, 72 
Regulators, air-, 357, 364. 369, 370, 

Fie 1 
Reichert, 258 
Related diseases of the eve and nose, 

116 
Relative frequency of diseases, 332- 

336 
Resection of drumhead, 443 
Reservoirs, air-, 357, 364, 365, 366, 369, 

370 
Retractor, epiglottis, 255 
Retractors for mastoid operations. 

490 
Retropharyngeal abscess, 240, Plate 

IV 
Reynolds, A. R., 193, 194. 196. 197 
Reynolds, D. S., 71 

Rheumatic sore throat, 154, 156. 199 
Rheumatism and gout, effects on ear, 

419 
Rhinitis acuta, 21 
clothing. 24 



5C2 



INDEX. 



Rhinitis acuta, complications, 23 

atrophica, 73 

hypertrophic^, -37 

simple chronic, 24 
Rhinoliths, 82 
Rhinorrhoea, 24, 27 
Rhinoscopic instruments, 3-7 
Rhinoscopy, 5, 6 
Rhodes, J." E., 274 
Rice, C. C, 75 
Richards, H., 373 
Richey, S. 0., 419, 429, 467 
Rhine's test for hearing, 349 
Robinson, Beverlv, 56 
Roe, John 0., 55, 288 
Roof of tympanum, Figs. 170, 193. 

219, 220, 221 
Roosa, D. B. St. J., 120, 394 
Rosenmiiller's fossa, Plate I 
Rouge, 133 

Roux, 167, 187, 188 
Roy, 38 
Ruedo, 467 

Rumbold, Thomas F., 118, 135 
Frank, 481 

Sajous, Charles E. de M., 6, 55, 153. 

220, 228, 288, 300 
Salpingitis, Eustachian, 398 
Sarcoma of larynx, 325 

of nose, 84 

of pharynx, 239 
Sattler, R., 115 

Saw in nasal deformities, 70, 72 
Scalds of the pharynx, 245 
Scarlatina, pharynx in, 160 
Schadle, J. E., 139 
Schaeffer, 112 
Scheibe, 481 

Scheppegrell, William, 71, 103 
Schiff, A., 72 
Schrotter, 295, 311 
Schwabach's test for hearing, 348 
Schwalbe, 237 
Schwartze, 492, 515, 523 
Schweinitz, G. E. de, 117 
Sclerosis of mastoid, 481 

middle ear, 418 
Scrofula, 220 
Scroll -oar, 382 

Sea-bathing, effect on ear, 402 
Setter, Carl, 56 
Seiss, Ralph \\\, r,: } . 68, 69, MS 

Semon, 130 

Senn, X.. 236 

Septum nasi, diseases and deformities, 
93, 97 

knife, 70 

perforation, 95, 98 
Sequels of middle-ear suppuration, 156 



Sequestra from ear, 468, 471 

Serous otitis media, 412 

Sex, influence, in disease, 72. 224, 331, 

332, 333, 336 
Sexton, Samuel, 437, 443, 466 
Sexual anomalies, effects on voice, 300 
Sexual organs and the nose, 72 
Shaffer, 86 
Sherrington, 38 
Shrapnell's membrane, Fig. 118, Plate 

VIII 
Shurly, E. L., 54, 288, 290 
Singer's nodule, 319 
Sinus, inferior petrosal, Fig. 193 

lateral, Figs. 190, 193, 208, 209, 212, 
213, 214, 222 
Sinuses, accessor} 7 , of nose, 104 

ethmoid, 109 

frontal, 112 

maxillary, 104 

sphenoid, 110 
Sinus-phlebitis and sinus-thrombosis, 

477 
Small-pox, throat in, 161 
Smell, sense of, 92, 93 
Smith, A. H., 396 
Smith, J. Lewis, 170, 180, 183 
Snare, ear, 457 
Sokolowski, 204 

Solis-Cohen, J., 55, 221, 222. 311 
Solutions, antiseptic, Appendix 
Somers, L. A., 77 
Sore throat, acute, 147 

chronic, 153 

clergyman's, 161 

common membranous, 164 

exudative, 161 

follicular, 161 

gouty, 154, 156 

granular, 161 

hypertrophic, 161 

measles, 159 

phlegmonous, 19S 

rheumatic, 154, 156 

scarlet fever, 160 

small-pox, 161 
Spasm of larynx. 270 

of pharynx, 243 
Spasmodic croup, 296 
Spear. E. D.. 517, 518 
Specula, aural, 341 

nasal, 4 

Siegle's pneumatic, 426 
Speech in testing the hearing. 351 
Sphenoid sinuses. 1 ID 

diseases of. effect on eye. 112 

tumors, 1 12 
Sphenopalatine ganglion. 31 
Spit/ka. E. ('.. 3b0 
Spots, genital, in nose, 72 






INDEX. 



Sprays, 8, 12 

for middle ear, 361, 362 
Spurious croup, 261 
Stacke's operation, 504 
Stapes, Figs. 157, 189, 192, 210. 220, 
221 

mobilization of, 443 

removal of, 439-444 
Statistics, 194, 196, 307, 332-336, 527 
Stein, O. J., 317 
Stenosis of Eustachian tube, 398, 401 

of larynx, 293, 305, 308, 310, 311 

of nasal cavities, 22, 44, 59, 81. 205, 
240 

of pharynx, 225, 227, 230, 232, 240 
Sterilizing instruments, 136, 177, 178, 

180, 431 
Strabismus from nasal disease, 121 
Stridulous laryngitis, 263 
Stucky, J. A., 526 
Subjective sounds, 385, 391, 398, 400, 

403, 415, 421, 519 
Supporter, nasal, 89 
Suprarenal solution, 66, 72, 77 
Synechia of nasal cavities, 57, 81 
Syphilis of auricle, 380 

internal ear, 517 

larynx, 308 

nasal cavities, 87 

pharynx, 222 
Syphilitic stenosis of larynx, 308, 310, 

311 
Syringes, 385, 386 

Tables, statistical, 194 
Tablets, coryza, 21 

cough-, 151 

throat-, 151 
Talbot, E. S., 380 
Tamponing nares, 77 
Teeth, carious, 104, 214 
Tegmen mastoideum, Figs. 193, 214, 

219, 220, 221 

tympani, Figs. 193, 214, 219, 220, 
221 
Temporal bone, Figs. 190, 192, 208, 
209, 210, 212, 213, 214, 219. 

220, 221 

caries of, 449, 457, 467 
Tensor tympani, Fig. 148 

tendon of, Fig. 147 

tenotomy of, 437 
Tests for hearing, 346-353 

acoumeter, 350 

Binges test, 350 

expressions for, 346 

Galton's whistle, 350 

Gelle's test, 350 

Rhine's test, 349 

Schwabach's test, 348 



Tests for hearing, speech, 351 
tuning-forks, automatic, 347 

Hartmann's, 348 
watch, 346 
Weber's method, 349 
whispers, 351 
Thomas, H. M., 11, 215 
Thompson, St. Clair, 27 
Thorner, Max, 147, 257 
Throat-tablets, 151 
Thrombosis of sinuses, 450, 477 

and jugulars, 477 
Tinnitus aurium, 385, 391, 398, 400, 

403, 415, 421, 519 
Toeplitz, Max, 215, 326, 468, 518 
Tongue-depressor, 5 
Tonsil, calculi, 215 
concretions, 215 
enlarged, 204 
hypertrophy of oral, 204 

pharyngeal, 134 
mycosis, 214 
of Luschka, 134 
pharyngeal, 134 
syphilis, 225 
tuberculosis, 204, 219 
Tonsillitis, acute, 198 
chronic, 204 

from nasal cauterization, 69, 199 
phlegmonous. 202 
treatment, 201, 207 
Tonsillotome, 208 
Tonsillotomy, 207 
Tonsils, acute inflammation, 198 
chronic inflammation, 204 

adenoids in vault of pharynx, 134 
aural symptoms from, 134, 199, 

205, 206 
crypts of, 198, 204, 214 
treatment, 207 

anaesthetics, 207, 212 
haemorrhage from tonsillotomy, 

210, 211, 212 
hot snare, 212 
tonsillotome, 208 
tonsillotomy, 207 
hypertrophied, 204 
lacunas of, 198, 204, 214 
large, 204 
parasites in, 214 
varieties of inflammation, 19S 
Toynbee's auscultation-tube, Fig. 138 
Tracheotomy, 279 

choice of operation, 280 
high operation, 280 
low operation, 282 
Trachoma from nasal disease, 120 

of vocal cords, 286, 292 
Transfixion needles in nasal hyper- 
trophies, 69, Plate IV 



564 



INDEX. 




Transformer, electric, 05, 66 

Transillumination, 114 

Trelat, 218 

Trephines, electric, 71 

Tuberculin in tuberculosis, 221, 307 

'i'uberculocidin in tuberculosis, 221 

Tuberculosis, effect on ear, 448 

larynx, 304 

nasal cavities, 80 

pharynx, 204, 219 
Tumors of antrum of Highmore, 109 

auricle, 378, 379 

frontal sinus, 115 

larynx, 312, 320 

metastatic, 239 

nasal cavities, 79-81, 97 

naso-pharynx, 131, 133, 134 

pharynx, 234 
Tuning-fork, automatic, 347 
Turbinated bodies, Figs. 26, 27, 28, 
29, 30, 55, 56, 57, 59, 00, 01, 
62, 65, 68, Plates I, II, III, 
IV 
Turk, F. B., 18 
Turnbull, 531 
Tympanic cavity, Figs. 220, 221 

floor of, Fig. 170 

inner wall, Figs. 220, 221 

mucous membrane, 450 

outer wall, Figs. 148, 165 
Tympanum. See Tympanic cavity. 
Tyrrell, Shawe, 38 

Umbo of membrana tvmpani, Plate 

VIII 
Urbantschitsch, 530 
Uricacidsemia, 36 

Uterine reflex neuroses of larynx, 300 
Uvula, Plates I, III, IV 

bifid and double, 217 
Uvulitis, 216 

Valsalva's inflation, 360, 416, 430 

Van der Poel, 141 

Vaporizers, 10-15 

Vapors, use of, in ear, 301, 302, 303, 

304 
Varicose veins in throat, 1").'! 
Variola, pharynx in, 101 
Vegetable parasites in ear, 390 
Vegetations in nasopharynx, 134 
Veil Ion, A., 198 



Velum palati, Plates I, III, IV 
Vertigo, 112, 121, 385, 388, 400, 401, 
415, 422, 449, 407, 473, 474, 
514, 515, 510, 517, 524, 525 
Vestibule, Figs. 208, 212 
Vibrator, ossicle, 433 
Vibratory massage, 74 
Virchow,' Rudolph, 170. 204, 238, 318, 

321, 383, 402, 533 
Visual field, contraction from nasal 

disease, 122 
Vocal cords, granulations of, 292 

trachoma, 292 
Voice in laryngeal diseases, 201. 262, 
209, 284, 285, 280, 287. 290, 
293, 299, 300, 305, 309, 313, 
321 
in nasal diseases, 23, 59, 135 
in pharyngeal diseases, 148, 102, 

. 205, 213. 230, 239, 240 
in sexual abnormalities, 300 
reflex affections of,' 300 
Vulpius, 483 

Wagner, Clinton, 09 
Waldeyer, 212 
Watch-test for hearing, 346 
Wax in ear. 384 
Weaver, W. H., 427 
Weber nasal douche, 9 
Weber's test for hearing, 349 
Webster, 515 
Welch, W. H., 107, 193 
Whisper-test for hearing, 351 
Whistle, Galton's, 350 
Whitaker, H. W., 215 
White, J. A.. 0. 22. 49 
Wilde's incision. 485 
Wile, William C, 181 
Witzel. 142 

Wolfenden. Norris, 204, 307 
Wright, Jonathan, 54 
Wiirdemann, H. V., 425, 438 
Wyman, Morrill, 32 

X-ray. 85, 232 

Yersin, 169 

Zaufal, 47 ti 

Zh'inssen. 284, 286, 322 

Zuckerkandl, 94 



